2016 innovation health leap drug guide acamprosate calcium · 2020-05-28 · quantity limits:...
TRANSCRIPT
![Page 1: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1.jpg)
2016 Innovation Health Leap Drug Guide
Acamprosate CalciumProducts Affected
• acamprosate calcium
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1
![Page 2: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/2.jpg)
Accu-Chek ActiveProducts Affected
• ACCU-CHEK ACTIVE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
2
![Page 3: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/3.jpg)
Accu-Chek AvivaProducts Affected
• ACCU-CHEK AVIVA IN VITRO STRIP
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
3
![Page 4: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/4.jpg)
Accu-Chek Aviva PlusProducts Affected
• ACCU-CHEK AVIVA PLUS IN VITRO
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
4
![Page 5: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/5.jpg)
Accu-Chek Compact PlusProducts Affected
• ACCU-CHEK COMPACT PLUS
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
5
![Page 6: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/6.jpg)
Accu-Chek Compact Test DrumProducts Affected
• ACCU-CHEK COMPACT TEST DRUM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
6
![Page 7: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/7.jpg)
Accu-Chek SmartViewProducts Affected
• ACCU-CHEK SMARTVIEW
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
7
![Page 8: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/8.jpg)
Accutrend GlucoseProducts Affected
• ACCUTREND GLUCOSE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
8
![Page 9: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/9.jpg)
AcitretinProducts Affected
• acitretin
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
9
![Page 10: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/10.jpg)
ActemraProducts Affected
• ACTEMRA INTRAVENOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST CriteriaRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
10
![Page 11: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/11.jpg)
ActimmuneProducts Affected
• ACTIMMUNE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/actimmune.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
11
![Page 12: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/12.jpg)
Actoplus met XRProducts Affected
• ACTOPLUS MET XR
ST Criteria Documented step through METFORMIN 1500MG/day
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
12
![Page 13: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/13.jpg)
Acura Blood Glucose TestProducts Affected
• ACURA BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
13
![Page 14: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/14.jpg)
AcuvailProducts Affected
• ACUVAIL
QL Criteria 1 vial Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
14
![Page 15: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/15.jpg)
AdapaleneProducts Affected
• adapalene external lotion
ST Criteria Documented step through TRETINOIN
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
15
![Page 16: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/16.jpg)
AdcircaProducts Affected
• ADCIRCA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST CriteriaRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
16
![Page 17: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/17.jpg)
Adefovir DipivoxilProducts Affected
• adefovir dipivoxil
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
17
![Page 18: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/18.jpg)
Advair DiskusProducts Affected
• ADVAIR DISKUS
ST Criteria Documented step through DULERA
QL Criteria 1 inhaler Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
18
![Page 19: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/19.jpg)
Advair HFAProducts Affected
• ADVAIR HFA
ST Criteria Documented step through DULERA
QL Criteria 1 inhaler Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
19
![Page 20: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/20.jpg)
Advance Intuition MeterProducts Affected
• ADVANCE INTUITION METER
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
20
![Page 21: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/21.jpg)
Advance Intuition TestProducts Affected
• ADVANCE INTUITION TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
21
![Page 22: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/22.jpg)
AdvateProducts Affected
• ADVATE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
22
![Page 23: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/23.jpg)
AdvicorProducts Affected
• ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 1000-20 MG
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
23
![Page 24: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/24.jpg)
AdvicorProducts Affected
• ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 750-20 MG
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
24
![Page 25: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/25.jpg)
AdvicorProducts Affected
• ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 1000-40 MG, 500-20 MG
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
25
![Page 26: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/26.jpg)
Advocate Blood Glucose MonitorProducts Affected
• ADVOCATE BLOOD GLUCOSE MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
26
![Page 27: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/27.jpg)
Advocate DuoProducts Affected
• ADVOCATE DUO DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
27
![Page 28: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/28.jpg)
Advocate Redi-CodeProducts Affected
• ADVOCATE REDI-CODE DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
28
![Page 29: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/29.jpg)
Advocate Redi-CodeProducts Affected
• ADVOCATE REDI-CODE IN VITRO
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
29
![Page 30: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/30.jpg)
Advocate Redi-Code+Products Affected
• ADVOCATE REDI-CODE+
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
30
![Page 31: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/31.jpg)
Advocate Redi-Code+ TestProducts Affected
• ADVOCATE REDI-CODE+ TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
31
![Page 32: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/32.jpg)
Advocate TestProducts Affected
• ADVOCATE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
32
![Page 33: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/33.jpg)
AdynovateProducts Affected
• adynovate
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
33
![Page 34: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/34.jpg)
Afeditab CRProducts Affected
• AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
34
![Page 35: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/35.jpg)
Afeditab CRProducts Affected
• AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
35
![Page 36: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/36.jpg)
AfinitorProducts Affected
• AFINITOR
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
36
![Page 37: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/37.jpg)
AgaMatrix AMP TestProducts Affected
• AGAMATRIX AMP TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
37
![Page 38: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/38.jpg)
AgaMatrix Jazz TestProducts Affected
• AGAMATRIX JAZZ TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
38
![Page 39: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/39.jpg)
AgaMatrix KeyNote TestProducts Affected
• AGAMATRIX KEYNOTE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
39
![Page 40: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/40.jpg)
AgaMatrix Presto Pro MeterProducts Affected
• AGAMATRIX PRESTO PRO METER
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
40
![Page 41: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/41.jpg)
AgaMatrix Presto TestProducts Affected
• AGAMATRIX PRESTO TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
41
![Page 42: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/42.jpg)
AkynzeoProducts Affected
• AKYNZEO
PA Criteria Criteria Details
Covered Uses Prophylaxis of nausea and vomiting associated with cancer chemotherapy
Exclusion Criteria
Required Medical Information
A documented diagnosis of nausea and vomiting associated with cancer chemotherapy
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 2 capsules Per 1 month
Notes/References Annual Review: 03/2016
Revision DatePrior Authorization: October 21, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
42
![Page 43: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/43.jpg)
AldurazymeProducts Affected
• ALDURAZYME
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
43
![Page 44: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/44.jpg)
Alendronate SodiumProducts Affected
• alendronate sodium oral tablet 10 mg, 40 mg, 5 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
44
![Page 45: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/45.jpg)
Alendronate SodiumProducts Affected
• alendronate sodium oral tablet 70 mg, 35 mg
QL Criteria 4 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
45
![Page 46: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/46.jpg)
Alfuzosin HCl ERProducts Affected
• alfuzosin hcl er
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
46
![Page 47: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/47.jpg)
AlimtaProducts Affected
• ALIMTA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
47
![Page 48: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/48.jpg)
Almotriptan MalateProducts Affected
• almotriptan malate
ST Criteria Documented step through TWO of the following: SUMATRIPTAN, NARATRIPTAN, RIZATRIPTAN
QL Criteria 6 tablets Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
48
![Page 49: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/49.jpg)
Alogliptin BenzoateProducts Affected
• alogliptin benzoate
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
49
![Page 50: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/50.jpg)
Alogliptin-Metformin HClProducts Affected
• alogliptin-metformin hcl
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
50
![Page 51: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/51.jpg)
Alogliptin-PioglitazoneProducts Affected
• alogliptin-pioglitazone
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
51
![Page 52: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/52.jpg)
AloxiProducts Affected
• ALOXI INTRAVENOUS* SOLUTION 0.25 MG/5ML
PA Criteria Criteria Details
Covered Uses
Prevention of acute or delayed nausea or vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy and prevention of postoperative nausea and vomiting (PONV) for up to 24 hours following surgery
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
Notes/References
Revision DatePrior Authorization: May 23, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
52
![Page 53: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/53.jpg)
Alphanate/VWF Complex/HumanProducts Affected
• ALPHANATE/VWF COMPLEX/HUMAN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
53
![Page 54: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/54.jpg)
AlphaNine SDProducts Affected
• ALPHANINE SD
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
54
![Page 55: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/55.jpg)
ALPRAZolam ERProducts Affected
• alprazolam er
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
55
![Page 56: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/56.jpg)
ALPRAZolam XRProducts Affected
• alprazolam xr
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
56
![Page 57: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/57.jpg)
AlprolixProducts Affected
• ALPROLIX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
57
![Page 58: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/58.jpg)
AltaveraProducts Affected
• ALTAVERA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
58
![Page 59: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/59.jpg)
AltoprevProducts Affected
• ALTOPREV
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
59
![Page 60: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/60.jpg)
AlvescoProducts Affected
• ALVESCO
ST Criteria Documented step through QVAR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
60
![Page 61: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/61.jpg)
Alyacen 1/35Products Affected
• alyacen 1/35
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
61
![Page 62: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/62.jpg)
AmethiaProducts Affected
• AMETHIA
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
62
![Page 63: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/63.jpg)
Amethia LoProducts Affected
• AMETHIA LO
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
63
![Page 64: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/64.jpg)
AmethystProducts Affected
• AMETHYST
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
64
![Page 65: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/65.jpg)
AmitizaProducts Affected
• AMITIZA
ST Criteria Documented step through LACTULOSE OR POLYETHYLENE GLYCOL
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
65
![Page 66: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/66.jpg)
Amlodipine Besylate-ValsartanProducts Affected
• amlodipine besylate-valsartan
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
66
![Page 67: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/67.jpg)
AmnesteemProducts Affected
• AMNESTEEM
ST Criteria Documented step through MINOCYCLINE OR DOXYCYCLINE
QL Criteria 2 capsules Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
67
![Page 68: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/68.jpg)
Amphetamine Salt ComboProducts Affected
• amphetamine salt combo
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
68
![Page 69: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/69.jpg)
Amphetamine-Dextroamphet ERProducts Affected
• amphetamine-dextroamphet er
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
69
![Page 70: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/70.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
70
![Page 71: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/71.jpg)
Amphetamine-DextroamphetamineProducts Affected
• amphetamine-dextroamphetamine
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
71
![Page 72: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/72.jpg)
AmpyraProducts Affected
• AMPYRA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
72
![Page 73: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/73.jpg)
AndrodermProducts Affected
• ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 1 patch Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
73
![Page 74: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/74.jpg)
AndroGelProducts Affected
• ANDROGEL TRANSDERMAL GEL 40.5 MG/2.5GM (1.62%)
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 5 grams-2 packets Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
74
![Page 75: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/75.jpg)
AndroGelProducts Affected
• ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%)
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 1 1.25 gm packet Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
75
![Page 76: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/76.jpg)
AndroGelProducts Affected
• ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%)
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 1 25 gram packet Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
76
![Page 77: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/77.jpg)
AndroGelProducts Affected
• ANDROGEL TRANSDERMAL GEL 50 MG/5GM (1%)
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 2 10 gm packets Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
77
![Page 78: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/78.jpg)
AndroGel PumpProducts Affected
• ANDROGEL PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%)
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 10 grams Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
78
![Page 79: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/79.jpg)
AndroGel PumpProducts Affected
• ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 4 pumps Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
79
![Page 80: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/80.jpg)
AnzemetProducts Affected
• ANZEMET ORAL
QL Criteria 5 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
80
![Page 81: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/81.jpg)
ApidraProducts Affected
• APIDRA
ST Criteria Documented step through HUMALOG product
QL Criteria 1 SOLN Per 180 FILLs
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
81
![Page 82: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/82.jpg)
Apidra SoloStarProducts Affected
• APIDRA SOLOSTAR SUBCUTANEOUS*
ST Criteria Documented step through HUMALOG product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
82
![Page 83: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/83.jpg)
ApriProducts Affected
• APRI
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
83
![Page 84: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/84.jpg)
AprisoProducts Affected
• APRISO
QL Criteria 4 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
84
![Page 85: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/85.jpg)
Aralast NPProducts Affected
• ARALAST NP
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/immunomodulators_CAP.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
85
![Page 86: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/86.jpg)
AranelleProducts Affected
• ARANELLE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
86
![Page 87: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/87.jpg)
Aranesp (Albumin Free)Products Affected
• ARANESP (ALBUMIN FREE) INJECTION SOLUTION 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 150 MCG/0.75ML, 10 MCG/0.4ML, 60 MCG/ML, 100 MCG/ML, 200 MCG/ML
• ARANESP (ALBUMIN FREE) INJECTION
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Erythropoiesis_Stimulating_Agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
87
![Page 88: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/88.jpg)
Aranesp (Albumin Free)Products Affected
• ARANESP (ALBUMIN FREE) INJECTION
PA Criteria Criteria Details
Covered Uses
Anemia from myelodysplastic syndrome; or Anemia of prematurity; or Special circumstance members who will not or can not receive whole blood or components as replacement for traumatic or surgical loss; or Treatment of anemic members scheduled to undergo hi
Exclusion Criteria
Non-covered uses include the following-Acute renal injury, Anemia associated only with radiotherapy, Anemia associated with the treatment of acute and chronic myelogenous leukemia (AML, CML) or erythroid cancers, Anemia due to bleeding (other than indicatio
Required Medical Information
A. Treatment of anemia associated with chronic kidney disease (CKD) receiving dialysis: Requirement of laboratory evidence: 1) Initiation hemoglobin (g/dL) is less than 10g/dL and Hemoglobin is not maintained above 11g/dL. Maintenance of Hct > 36% or a
Age Restrictions
Prescriber Restrictions
Coverage Duration
4 months
Other Criteria
1. Regardless of indication, member is experiencing symptomatic anemia, such as fatigue, weakness, shortness of breath, or lightheadedness that are significantly impacting the ability of the patient to perform necessary activities of daily living, Or if
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
88
![Page 89: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/89.jpg)
ArcalystProducts Affected
• ARCALYST
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/immunomodulators_CAP.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
89
![Page 90: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/90.jpg)
Arcapta NeohalerProducts Affected
• ARCAPTA NEOHALER
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
90
![Page 91: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/91.jpg)
ARIPiprazoleProducts Affected
• aripiprazole oral tablet dispersible • aripiprazole oral tablet
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
91
![Page 92: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/92.jpg)
ARIPiprazoleProducts Affected
• aripiprazole oral solution
QL Criteria 30 ml Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
92
![Page 93: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/93.jpg)
ArmodafinilProducts Affected
• armodafinil oral tablet 150 mg, 200 mg, 250 mg
PA Criteria Criteria Details
Covered Uses excessive daytime sleepiness, Shift Work Sleep Disorder
Exclusion Criteria Nuvigil is not indicated to treat side effects caused by other medications.
Required Medical Information
FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH NARCOLEPSY: Documentation of diagnostic testing and clinical notations supporting diagnosis of Narcolepsy, such as MSLT, clinical progress notes, etc. (Failure to adequately support the diagnosis of narcolepsy may result in denial of coverage), and the patient has failed an adequate trial of at least TWO of the following immediate release stimulants (all available generically): Dexedrine, Ritalin, or Adderall, and the patient has stepped through an adequate trial of modafinil (modafinil requires prior authorization). FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH OBSTRUCTIVE SLEEP APNEA/HYPOPNEA SYNDROME: The prescribing physician is a sleep specialist, ear, nose and throat, neurologist or pulmonologist or has obtained a consult from a sleep specialist, and a standard diagnostic nocturnal polysomnography (NPSG) has confirmed the diagnosis of OSAHS, and the patient has received nasal continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) for at least 1 month, and CPAP or BIPAP therapy must be continued on a routine basis in combination with armodafinil therapy, and the daytime fatigue is significantly impacting, impairing, or compromising the patients ability to function normally, and the prescribing physician has established a patient care plan to treat the cause of OSAHS in conjunction with treating the daily fatigue, and the patient must be compliant with recommendations for OSAHS treatment, and the patient has stepped through an adequate trial of modafinil (modafinil requires prior authorization).
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
Note: The plan also requires an unresponsive 2-week trial of 150mg per day dose before a 250mg per day dose is authorized. (Doses up to 250 mg/day can be used but there is no solid evidence that it provides additional benefit beyond 150 mg/day.)
2016 Innovation Health Leap Drug GuideLast update 12/2016
93
![Page 94: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/94.jpg)
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: November 09, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
94
![Page 95: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/95.jpg)
ArmodafinilProducts Affected
• armodafinil oral tablet 50 mg
PA Criteria Criteria Details
Covered Uses excessive daytime sleepiness, Shift Work Sleep Disorder
Exclusion Criteria Nuvigil is not indicated to treat side effects caused by other medications.
Required Medical Information
FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH NARCOLEPSY: Documentation of diagnostic testing and clinical notations supporting diagnosis of Narcolepsy, such as MSLT, clinical progress notes, etc. (Failure to adequately support the diagnosis of narcolepsy may result in denial of coverage), and the patient has failed an adequate trial of at least TWO of the following immediate release stimulants (all available generically): Dexedrine, Ritalin, or Adderall, and the patient has stepped through an adequate trial of modafinil (modafinil requires prior authorization). FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH OBSTRUCTIVE SLEEP APNEA/HYPOPNEA SYNDROME: The prescribing physician is a sleep specialist, ear, nose and throat, neurologist or pulmonologist or has obtained a consult from a sleep specialist, and a standard diagnostic nocturnal polysomnography (NPSG) has confirmed the diagnosis of OSAHS, and the patient has received nasal continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) for at least 1 month, and CPAP or BIPAP therapy must be continued on a routine basis in combination with armodafinil therapy, and the daytime fatigue is significantly impacting, impairing, or compromising the patients ability to function normally, and the prescribing physician has established a patient care plan to treat the cause of OSAHS in conjunction with treating the daily fatigue, and the patient must be compliant with recommendations for OSAHS treatment, and the patient has stepped through an adequate trial of modafinil (modafinil requires prior authorization).
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
Note: The plan also requires an unresponsive 2-week trial of 150mg per day dose before a 250mg per day dose is authorized. (Doses up to 250 mg/day can be used but there is no solid evidence that it provides additional benefit beyond 150 mg/day.)
2016 Innovation Health Leap Drug GuideLast update 12/2016
95
![Page 96: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/96.jpg)
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: November 09, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
96
![Page 97: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/97.jpg)
ArzerraProducts Affected
• ARZERRA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
97
![Page 98: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/98.jpg)
Ascensia Autodisc TestProducts Affected
• ASCENSIA AUTODISC TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
98
![Page 99: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/99.jpg)
Asmanex 120 Metered DosesProducts Affected
• ASMANEX 120 METERED DOSES
ST Criteria Documented step through QVAR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
99
![Page 100: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/100.jpg)
Asmanex 14 Metered DosesProducts Affected
• ASMANEX 14 METERED DOSES
ST Criteria Documented step through QVAR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
100
![Page 101: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/101.jpg)
Asmanex 30 Metered DosesProducts Affected
• ASMANEX 30 METERED DOSES
ST Criteria Documented step through QVAR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
101
![Page 102: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/102.jpg)
Asmanex 60 Metered DosesProducts Affected
• ASMANEX 60 METERED DOSES
ST Criteria Documented step through QVAR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
102
![Page 103: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/103.jpg)
Assure 3 TestProducts Affected
• ASSURE 3 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
103
![Page 104: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/104.jpg)
Assure 4 MeterProducts Affected
• ASSURE 4 METER
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
104
![Page 105: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/105.jpg)
Assure 4 TestProducts Affected
• ASSURE 4 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
105
![Page 106: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/106.jpg)
Assure PlatinumProducts Affected
• ASSURE PLATINUM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
106
![Page 107: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/107.jpg)
Assure Platinum MeterProducts Affected
• ASSURE PLATINUM METER
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
107
![Page 108: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/108.jpg)
Assure Pro Blood Glucose MeterProducts Affected
• ASSURE PRO BLOOD GLUCOSE METER
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
108
![Page 109: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/109.jpg)
Assure Pro TestProducts Affected
• ASSURE PRO TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
109
![Page 110: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/110.jpg)
Atorvastatin CalciumProducts Affected
• atorvastatin calcium oral
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
110
![Page 111: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/111.jpg)
AtriplaProducts Affected
• ATRIPLA
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
111
![Page 112: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/112.jpg)
AubagioProducts Affected
• AUBAGIO
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
112
![Page 113: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/113.jpg)
AvandametProducts Affected
• AVANDAMET ORAL TABLET 2-500 MG
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Diagnosis of Type 1 Diabetes (IDDM), patients with symptomatic heart failure or those who develop signs and symptoms of heart failure after initiation of Avandia therapy, patients with established New York Heart Association (NYHA) Class III or IV heart failure, patients with a history of myocardial infarction, concurrent use with insulin or Symlin.
Required Medical Information
A documented diagnosis of type 2 diabetes mellitus in an adult patient who is unable to achieve adequate glycemic control (HbA1C lab value greater than 6.5%) despite the use of other medications, and who, after consultation with their healthcare provider, has decided not to take Actos (pioglitazone) for medical reasons.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
113
![Page 114: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/114.jpg)
AvandametProducts Affected
• AVANDAMET ORAL TABLET 2-1000 MG
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Diagnosis of Type 1 Diabetes (IDDM), patients with symptomatic heart failure or those who develop signs and symptoms of heart failure after initiation of Avandia therapy, patients with established New York Heart Association (NYHA) Class III or IV heart failure, patients with a history of myocardial infarction, concurrent use with insulin or Symlin.
Required Medical Information
A documented diagnosis of type 2 diabetes mellitus in an adult patient who is unable to achieve adequate glycemic control (HbA1C lab value greater than 6.5%) despite the use of other medications, and who, after consultation with their healthcare provider, has decided not to take Actos (pioglitazone) for medical reasons.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
114
![Page 115: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/115.jpg)
AvandiaProducts Affected
• AVANDIA
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Diagnosis of Type 1 Diabetes (IDDM), patients with symptomatic heart failure or those who develop signs and symptoms of heart failure after initiation of Avandia therapy, patients with established New York Heart Association (NYHA) Class III or IV heart failure, patients with a history of myocardial infarction, concurrent use with insulin or Symlin.
Required Medical Information
A documented diagnosis of type 2 diabetes mellitus in an adult patient who is unable to achieve adequate glycemic control (HbA1C lab value greater than 6.5%) despite the use of other medications, and who, after consultation with their healthcare provider, has decided not to take Actos (pioglitazone) for medical reasons.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
115
![Page 116: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/116.jpg)
AvianeProducts Affected
• AVIANE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
116
![Page 117: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/117.jpg)
AvitaProducts Affected
• AVITA EXTERNAL CREAM
QL Criteria 50 grams Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
117
![Page 118: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/118.jpg)
AvonexProducts Affected
• AVONEX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
QL Criteria 4 doses Per 1 month
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
118
![Page 119: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/119.jpg)
Avonex PenProducts Affected
• AVONEX PEN INTRAMUSCULAR*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
119
![Page 120: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/120.jpg)
Avonex PrefilledProducts Affected
• AVONEX PREFILLED INTRAMUSCULAR*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
120
![Page 121: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/121.jpg)
AxironProducts Affected
• AXIRON
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 4 pumps Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
121
![Page 122: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/122.jpg)
AzilectProducts Affected
• AZILECT
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
122
![Page 123: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/123.jpg)
AzorProducts Affected
• AZOR
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
123
![Page 124: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/124.jpg)
AzuretteProducts Affected
• AZURETTE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
124
![Page 125: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/125.jpg)
Balsalazide DisodiumProducts Affected
• balsalazide disodium
QL Criteria 9 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
125
![Page 126: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/126.jpg)
BalzivaProducts Affected
• BALZIVA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
126
![Page 127: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/127.jpg)
BanzelProducts Affected
• BANZEL ORAL TABLET
PA Criteria Criteria Details
Covered Uses Adjunctive treatment of seizures associated with Lennox-Gastaut syndrome
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 8 tablets Per 1 day
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
127
![Page 128: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/128.jpg)
BanzelProducts Affected
• BANZEL ORAL SUSPENSION
PA Criteria Criteria Details
Covered Uses Adjunctive treatment of seizures associated with Lennox-Gastaut syndrome
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
128
![Page 129: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/129.jpg)
BaracludeProducts Affected
• BARACLUDE ORAL TABLET
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
129
![Page 130: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/130.jpg)
Bayer Breeze 2 TestProducts Affected
• BAYER BREEZE 2 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
130
![Page 131: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/131.jpg)
Bayer Contour MonitorProducts Affected
• BAYER CONTOUR MONITOR DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
131
![Page 132: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/132.jpg)
Bayer Contour Next TestProducts Affected
• BAYER CONTOUR NEXT TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
132
![Page 133: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/133.jpg)
Bayer Contour TestProducts Affected
• BAYER CONTOUR TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
133
![Page 134: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/134.jpg)
BebulinProducts Affected
• BEBULIN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
134
![Page 135: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/135.jpg)
Bebulin VHProducts Affected
• BEBULIN VH
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
135
![Page 136: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/136.jpg)
Beconase AQProducts Affected
• BECONASE AQ
ST Criteria Documented step through FLUTICASONE PROPIONATE AND FLUNISOLIDE
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
136
![Page 137: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/137.jpg)
BenicarProducts Affected
• BENICAR
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
137
![Page 138: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/138.jpg)
Benicar HCTProducts Affected
• BENICAR HCT
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
138
![Page 139: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/139.jpg)
BenlystaProducts Affected
• BENLYSTA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/benlysta.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
139
![Page 140: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/140.jpg)
BetaseronProducts Affected
• BETASERON SUBCUTANEOUS* KIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
QL Criteria 1 box (15 vials) Per 1 month
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
140
![Page 141: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/141.jpg)
BexaroteneProducts Affected
• bexarotene
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
141
![Page 142: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/142.jpg)
BG Star TestProducts Affected
• BG STAR TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
142
![Page 143: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/143.jpg)
BicalutamideProducts Affected
• bicalutamide
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
143
![Page 144: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/144.jpg)
BimatoprostProducts Affected
• bimatoprost ophthalmic
PA Criteria Criteria Details
Covered Uses Glaucoma
Exclusion Criteria
Required Medical Information
Documented step through latanoprost.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
144
![Page 145: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/145.jpg)
BivigamProducts Affected
• BIVIGAM
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
145
![Page 146: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/146.jpg)
BosulifProducts Affected
• BOSULIF ORAL TABLET 100 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 EA Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
146
![Page 147: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/147.jpg)
BosulifProducts Affected
• BOSULIF ORAL TABLET 500 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
147
![Page 148: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/148.jpg)
BotoxProducts Affected
• BOTOX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/botulinum_toxin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
148
![Page 149: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/149.jpg)
BravelleProducts Affected
• BRAVELLE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
149
![Page 150: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/150.jpg)
Breeze 2 Blood Glucose SystemProducts Affected
• BREEZE 2 BLOOD GLUCOSE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
150
![Page 151: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/151.jpg)
Brevicon (28)Products Affected
• BREVICON (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
151
![Page 152: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/152.jpg)
BriellynProducts Affected
• briellyn
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
152
![Page 153: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/153.jpg)
BrilintaProducts Affected
• BRILINTA
ST Criteria Documented step through CLOPIDOGREL
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
153
![Page 154: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/154.jpg)
BrovanaProducts Affected
• BROVANA
QL Criteria 4 milliliters Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
154
![Page 155: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/155.jpg)
BudesonideProducts Affected
• budesonide inhalation
PA Criteria Criteria Details
Covered Uses Asthma
Exclusion Criteria
Budesonide inhalation solution is NOT covered for members greater than 8 years of age, for children 5-8 years of age who are able to use metered-dose inhalers, for use in primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required, and for use in acute bronchospasms.
Required Medical Information
Covered for the maintenance treatment of asthma and as prophylactic therapy in children 1-4 years of age, or in children 5-8 years of age if unable to use metered dose inhalers.
Age Restrictions Less than 8 years of age
Prescriber Restrictions
Coverage Duration
1 Year, up to the age of 8 years of age
Other CriteriaMedical Exception: Covered for topical steroid treatment of eosinophilic esophagitis for which other treatments have been unsatisfactory
Notes/References
Revision DatePrior Authorization: November 24, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
155
![Page 156: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/156.jpg)
BunavailProducts Affected
• BUNAVAIL
PA Criteria Criteria Details
Covered UsesOpioid Dependence. NOTE: Prior Authorization does not apply to members residing in Massachusetts.
Exclusion Criteria
Medical literature does not support the concurrent use of opioids/Tramadol as part of opioid drug dependence treatment. Abstinence of opioids/Tramadol is required both during and following therapy with Suboxone/Subutex/Zubsolv/Bunavail/buprenorphine, and will only be covered when determined to be medically necessary (defined as short-term use during and following opioid dependence treatment for the treatment of acute pain related to surgery, dental procedure, or an emergency situation or for long-term use following opioid dependence treatment for the treatment of chronic pain. For long term use, the member must be treated by a single provider of their choice, opioids will only be covered when prescribed by this single provider, and this single provider is aware of past buprenorphine use for opioid dependence treatment in which an opioid dependence diagnosis). Physicians can contact (855) 746-0013 with any information related to the medical necessity for opioid/Tramadol therapy.
Required Medical Information
Prescriber provides verbal verification of patient's current and ongoing enrollment in an outpatient drug addiction treatment program/ counseling. If the member is currently enrolled, the approval will be 6 months. If the member is NOT enrolled (answer=no) and prescriber provides verbal verification of patient's agreed commitment to become enrolled in an acceptable drug addiction treatment program counseling, the approval will be for 2 months (Note: 1 time approval ONLY). If after 2 months member does not enroll in a program, then all future requests will be denied until member enrolls in a program.
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 months = current enrollement
2016 Innovation Health Leap Drug GuideLast update 12/2016
156
![Page 157: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/157.jpg)
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, the following conditions must be met: FOR BUPRENORPHONE SL: Member is pregnant or breastfeeding (Up to 120 tablets in 30 days)or member has a documented contraindication, intolerance, or allergy to buprenorphine-naloxone sublingual tablet or Suboxone (will allow up to 90 tablets per month for max length of approval of 6 months). FOR SUBOXONE OR BUPRENORPHINE-NALOXONE SUBLINGUAL TABLET 2mg/0.5mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 12 mg/daily for total of 42 tablets/films in 7 days). FOR ZUBSOLBV 1.4mg/0.36mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 8.4 mg/daily for total of 42 tablets/films in 7 days). Note: Aetna considers the following as acceptable programs: Outpatient drug addiction treatment programs and/or counseling, 12- step programs focused on "drug" addiction such as Narcotics Anonymous (N.A.), Other accepted programs can be found at http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx. Aetna considers the following as non-acceptable programs: On-line programs such as Here to Help, 12-step programs that are not focused on "drug" addiction (ex: Alcoholics Anonymous).
ST Criteria A documented step through one month each of the preferred alternatives, buprenorphine-naloxone sublingual tablet and Suboxone SL film
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
157
![Page 158: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/158.jpg)
BuphenylProducts Affected
• BUPHENYL ORAL TABLET
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 31, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
158
![Page 159: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/159.jpg)
Buprenorphine HClProducts Affected
• buprenorphine hcl sublingual tablet sublingual8 mg
PA Criteria Criteria Details
Covered UsesOpioid Dependence. NOTE: Prior Authorization does not apply to members residing in Massachusetts.
Exclusion Criteria
Medical literature does not support the concurrent use of opioids/Tramadol as part of opioid drug dependence treatment. Abstinence of opioids/Tramadol is required both during and following therapy with Suboxone/Subutex/Zubsolv/Bunavail/buprenorphine, and will only be covered when determined to be medically necessary (defined as short-term use during and following opioid dependence treatment for the treatment of acute pain related to surgery, dental procedure, or an emergency situation or for long-term use following opioid dependence treatment for the treatment of chronic pain. For long term use, the member must be treated by a single provider of their choice, opioids will only be covered when prescribed by this single provider, and this single provider is aware of past buprenorphine use for opioid dependence treatment in which an opioid dependence diagnosis). Physicians can contact (855) 746-0013 with any information related to the medical necessity for opioid/Tramadol therapy.
Required Medical Information
Prescriber provides verbal verification of patient's current and ongoing enrollment in an outpatient drug addiction treatment program/ counseling. If the member is currently enrolled, the approval will be 6 months. If the member is NOT enrolled (answer=no) and prescriber provides verbal verification of patient's agreed commitment to become enrolled in an acceptable drug addiction treatment program counseling, the approval will be for 2 months (Note: 1 time approval ONLY). If after 2 months member does not enroll in a program, then all future requests will be denied until member enrolls in a program.
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 months = current enrollement
2016 Innovation Health Leap Drug GuideLast update 12/2016
159
![Page 160: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/160.jpg)
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, the following conditions must be met: FOR BUPRENORPHONE SL: Member is pregnant or breastfeeding (Up to 120 tablets in 30 days)or member has a documented contraindication, intolerance, or allergy to buprenorphine-naloxone sublingual tablet or Suboxone (will allow up to 90 tablets per month for max length of approval of 6 months). FOR SUBOXONE OR BUPRENORPHINE-NALOXONE SUBLINGUAL TABLET 2mg/0.5mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 12 mg/daily for total of 42 tablets/films in 7 days). FOR ZUBSOLBV 1.4mg/0.36mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 8.4 mg/daily for total of 42 tablets/films in 7 days). Note: Aetna considers the following as acceptable programs: Outpatient drug addiction treatment programs and/or counseling, 12- step programs focused on "drug" addiction such as Narcotics Anonymous (N.A.), Other accepted programs can be found at http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx. Aetna considers the following as non-acceptable programs: On-line programs such as Here to Help, 12-step programs that are not focused on "drug" addiction (ex: Alcoholics Anonymous).
QL Criteria 3 tablets Per 1 Day
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
160
![Page 161: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/161.jpg)
Buprenorphine HClProducts Affected
• buprenorphine hcl sublingual tablet sublingual2 mg
PA Criteria Criteria Details
Covered UsesOpioid Dependence. NOTE: Prior Authorization does not apply to members residing in Massachusetts.
Exclusion Criteria
Medical literature does not support the concurrent use of opioids/Tramadol as part of opioid drug dependence treatment. Abstinence of opioids/Tramadol is required both during and following therapy with Suboxone/Subutex/Zubsolv/Bunavail/buprenorphine, and will only be covered when determined to be medically necessary (defined as short-term use during and following opioid dependence treatment for the treatment of acute pain related to surgery, dental procedure, or an emergency situation or for long-term use following opioid dependence treatment for the treatment of chronic pain. For long term use, the member must be treated by a single provider of their choice, opioids will only be covered when prescribed by this single provider, and this single provider is aware of past buprenorphine use for opioid dependence treatment in which an opioid dependence diagnosis). Physicians can contact (855) 746-0013 with any information related to the medical necessity for opioid/Tramadol therapy.
Required Medical Information
Prescriber provides verbal verification of patient's current and ongoing enrollment in an outpatient drug addiction treatment program/ counseling. If the member is currently enrolled, the approval will be 6 months. If the member is NOT enrolled (answer=no) and prescriber provides verbal verification of patient's agreed commitment to become enrolled in an acceptable drug addiction treatment program counseling, the approval will be for 2 months (Note: 1 time approval ONLY). If after 2 months member does not enroll in a program, then all future requests will be denied until member enrolls in a program.
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 months = current enrollement
2016 Innovation Health Leap Drug GuideLast update 12/2016
161
![Page 162: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/162.jpg)
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, the following conditions must be met: FOR BUPRENORPHONE SL: Member is pregnant or breastfeeding (Up to 120 tablets in 30 days)or member has a documented contraindication, intolerance, or allergy to buprenorphine-naloxone sublingual tablet or Suboxone (will allow up to 90 tablets per month for max length of approval of 6 months). FOR SUBOXONE OR BUPRENORPHINE-NALOXONE SUBLINGUAL TABLET 2mg/0.5mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 12 mg/daily for total of 42 tablets/films in 7 days). FOR ZUBSOLBV 1.4mg/0.36mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 8.4 mg/daily for total of 42 tablets/films in 7 days). Note: Aetna considers the following as acceptable programs: Outpatient drug addiction treatment programs and/or counseling, 12- step programs focused on "drug" addiction such as Narcotics Anonymous (N.A.), Other accepted programs can be found at http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx. Aetna considers the following as non-acceptable programs: On-line programs such as Here to Help, 12-step programs that are not focused on "drug" addiction (ex: Alcoholics Anonymous).
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
162
![Page 163: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/163.jpg)
Buprenorphine HCl-Naloxone HClProducts Affected
• buprenorphine hcl-naloxone hcl
PA Criteria Criteria Details
Covered UsesOpioid Dependence. NOTE: Prior Authorization does not apply to members residing in Massachusetts.
Exclusion Criteria
Medical literature does not support the concurrent use of opioids/Tramadol as part of opioid drug dependence treatment. Abstinence of opioids/Tramadol is required both during and following therapy with Suboxone/Subutex/Zubsolv/Bunavail/buprenorphine, and will only be covered when determined to be medically necessary (defined as short-term use during and following opioid dependence treatment for the treatment of acute pain related to surgery, dental procedure, or an emergency situation or for long-term use following opioid dependence treatment for the treatment of chronic pain. For long term use, the member must be treated by a single provider of their choice, opioids will only be covered when prescribed by this single provider, and this single provider is aware of past buprenorphine use for opioid dependence treatment in which an opioid dependence diagnosis). Physicians can contact (855) 746-0013 with any information related to the medical necessity for opioid/Tramadol therapy.
Required Medical Information
Prescriber provides verbal verification of patient's current and ongoing enrollment in an outpatient drug addiction treatment program/ counseling. If the member is currently enrolled, the approval will be 6 months. If the member is NOT enrolled (answer=no) and prescriber provides verbal verification of patient's agreed commitment to become enrolled in an acceptable drug addiction treatment program counseling, the approval will be for 2 months (Note: 1 time approval ONLY). If after 2 months member does not enroll in a program, then all future requests will be denied until member enrolls in a program.
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 months = current enrollement
2016 Innovation Health Leap Drug GuideLast update 12/2016
163
![Page 164: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/164.jpg)
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, the following conditions must be met: FOR BUPRENORPHONE SL: Member is pregnant or breastfeeding (Up to 120 tablets in 30 days)or member has a documented contraindication, intolerance, or allergy to buprenorphine-naloxone sublingual tablet or Suboxone (will allow up to 90 tablets per month for max length of approval of 6 months). FOR SUBOXONE OR BUPRENORPHINE-NALOXONE SUBLINGUAL TABLET 2mg/0.5mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 12 mg/daily for total of 42 tablets/films in 7 days). FOR ZUBSOLBV 1.4mg/0.36mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 8.4 mg/daily for total of 42 tablets/films in 7 days). Note: Aetna considers the following as acceptable programs: Outpatient drug addiction treatment programs and/or counseling, 12- step programs focused on "drug" addiction such as Narcotics Anonymous (N.A.), Other accepted programs can be found at http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx. Aetna considers the following as non-acceptable programs: On-line programs such as Here to Help, 12-step programs that are not focused on "drug" addiction (ex: Alcoholics Anonymous).
QL Criteria 3 tablets Per 1 day
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
164
![Page 165: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/165.jpg)
BuprobanProducts Affected
• BUPROBAN
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
165
![Page 166: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/166.jpg)
BuPROPion HClProducts Affected
• bupropion hcl oral
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
166
![Page 167: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/167.jpg)
BuPROPion HCl ER (Smoking Det)Products Affected
• bupropion hcl er (smoking det)
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
167
![Page 168: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/168.jpg)
BuPROPion HCl ER (SR)Products Affected
• bupropion hcl er (sr)
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
168
![Page 169: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/169.jpg)
BuPROPion HCl ER (XL)Products Affected
• bupropion hcl er (xl)
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
169
![Page 170: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/170.jpg)
Butorphanol TartrateProducts Affected
• butorphanol tartrate nasal
QL Criteria 2 bottles Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
170
![Page 171: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/171.jpg)
ButransProducts Affected
• BUTRANS TRANSDERMAL PATCH WEEKLY 20 MCG/HR, 10 MCG/HR, 5 MCG/HR
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
QL Criteria 1 box (4 patches) Per 1 month
Notes/References
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
171
![Page 172: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/172.jpg)
BydureonProducts Affected
• BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED
PA Criteria Criteria Details
Covered Uses Type 2 Diabetes Mellitus (NIDDM)
Exclusion Criteria
Diagnosis of metabolic syndrome or any other pre-diabetic diagnosis, diagnosis of Type 1 Diabetes, treatment of diabetic ketoacidosis, pediatric patients, patients with multiple endocrine neoplasia syndrome type 2 (MEN2), family history of medullary thyroid carcinoma (MTC), patients with a history of pancreatitis
Required Medical Information
Patient must an A1C level is greater than 6.5%, have failed to obtain adequate glycemic control on maximum tolerated dose of metformin (unless the patient is not a candidate for metformin therapy) and a second antidiabetic agent (either a sulfonylurea, a thiazolidinedione (TZD), a DPP4-inhibitor or basal insulin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 4 vials Per 1 month
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
172
![Page 173: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/173.jpg)
Byetta 10 MCG PenProducts Affected
• BYETTA 10 MCG PEN SUBCUTANEOUS*
PA Criteria Criteria Details
Covered Uses Type 2 Diabetes Mellitus (NIDDM)
Exclusion Criteria
Diagnosis of metabolic syndrome or any other pre-diabetic diagnosis, diagnosis of Type 1 Diabetes, treatment of diabetic ketoacidosis, pediatric patients, patients with multiple endocrine neoplasia syndrome type 2 (MEN2), family history of medullary thyroid carcinoma (MTC), patients with a history of pancreatitis
Required Medical Information
Patient must an A1C level is greater than 6.5%, have failed to obtain adequate glycemic control on maximum tolerated dose of metformin (unless the patient is not a candidate for metformin therapy) and a second antidiabetic agent (either a sulfonylurea, a thiazolidinedione (TZD), a DPP4-inhibitor or basal insulin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 1 pen Per 1 month
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
173
![Page 174: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/174.jpg)
Byetta 5 MCG PenProducts Affected
• BYETTA 5 MCG PEN SUBCUTANEOUS*
PA Criteria Criteria Details
Covered Uses Type 2 Diabetes Mellitus (NIDDM)
Exclusion Criteria
Diagnosis of metabolic syndrome or any other pre-diabetic diagnosis, diagnosis of Type 1 Diabetes, treatment of diabetic ketoacidosis, pediatric patients, patients with multiple endocrine neoplasia syndrome type 2 (MEN2), family history of medullary thyroid carcinoma (MTC), patients with a history of pancreatitis
Required Medical Information
Patient must an A1C level is greater than 6.5%, have failed to obtain adequate glycemic control on maximum tolerated dose of metformin (unless the patient is not a candidate for metformin therapy) and a second antidiabetic agent (either a sulfonylurea, a thiazolidinedione (TZD), a DPP4-inhibitor or basal insulin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 1 pen Per 1 month
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
174
![Page 175: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/175.jpg)
BystolicProducts Affected
• BYSTOLIC ORAL TABLET 20 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
175
![Page 176: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/176.jpg)
BystolicProducts Affected
• BYSTOLIC ORAL TABLET 2.5 MG, 5 MG, 10 MG
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
176
![Page 177: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/177.jpg)
CalcipotrieneProducts Affected
• calcipotriene external
ST Criteria Documented step through of trial and failure of MEDIUM TO HIGH POTENCY TOPICAL STEROID
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
177
![Page 178: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/178.jpg)
Calcipotriene-Betameth DipropProducts Affected
• calcipotriene-betameth diprop
ST Criteria Documented step through CALCIPOTRIENE AND MEDIUM TO HIGH POTENCY TOPICAL STEROID
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
178
![Page 179: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/179.jpg)
Calcitonin (Salmon)Products Affected
• calcitonin (salmon)
PA Criteria Criteria Details
Covered Uses Osteoporosis
Exclusion CriteriaNo failure of formulary bisphosphonates, use in combination with one or more bisphosphonates.
Required Medical Information
Documentation of a trial and failure of generic alendronate weekly (70mg weekly dose)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 bottle Per 1 month
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
179
![Page 180: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/180.jpg)
CalcitreneProducts Affected
• CALCITRENE
ST Criteria Documented step through of trial and failure of MEDIUM TO HIGH POTENCY TOPICAL STEROID
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
180
![Page 181: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/181.jpg)
CamilaProducts Affected
• CAMILA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
181
![Page 182: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/182.jpg)
CamreseProducts Affected
• CAMRESE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
182
![Page 183: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/183.jpg)
Camrese LoProducts Affected
• CAMRESE LO
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
183
![Page 184: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/184.jpg)
CanasaProducts Affected
• CANASA
ST Criteria Documented failure, contraindication or intolerance to Apriso
QL Criteria 1 suppository Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
184
![Page 185: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/185.jpg)
Candesartan CilexetilProducts Affected
• candesartan cilexetil oral tablet 4 mg, 8 mg, 16 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
185
![Page 186: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/186.jpg)
Candesartan Cilexetil-HCTZProducts Affected
• candesartan cilexetil-hctz
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
186
![Page 187: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/187.jpg)
CapecitabineProducts Affected
• capecitabine
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
187
![Page 188: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/188.jpg)
CaprelsaProducts Affected
• CAPRELSA ORAL TABLET 100 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
188
![Page 189: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/189.jpg)
CaprelsaProducts Affected
• CAPRELSA ORAL TABLET 300 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
189
![Page 190: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/190.jpg)
CarbagluProducts Affected
• CARBAGLU
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 31, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
190
![Page 191: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/191.jpg)
Cardura XLProducts Affected
• CARDURA XL
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
191
![Page 192: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/192.jpg)
CareSens N Glucose SystemProducts Affected
• CARESENS N GLUCOSE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
192
![Page 193: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/193.jpg)
CareSens N Glucose TestProducts Affected
• CARESENS N GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
193
![Page 194: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/194.jpg)
Carimune NFProducts Affected
• CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 6 GM, 12 GM
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
194
![Page 195: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/195.jpg)
Cartia XTProducts Affected
• CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 300 MG, 180 MG
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
195
![Page 196: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/196.jpg)
Cartia XTProducts Affected
• CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
196
![Page 197: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/197.jpg)
CaystonProducts Affected
• CAYSTON
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
197
![Page 198: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/198.jpg)
CaziantProducts Affected
• CAZIANT
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
198
![Page 199: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/199.jpg)
CefiximeProducts Affected
• cefixime
QL Criteria 1 bottle Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
199
![Page 200: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/200.jpg)
CelecoxibProducts Affected
• celecoxib oral
ST Criteria Documented step through TWO NSAIDs
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
200
![Page 201: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/201.jpg)
CerdelgaProducts Affected
• CERDELGA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 capsules Per 1 days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
201
![Page 202: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/202.jpg)
CerezymeProducts Affected
• CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
202
![Page 203: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/203.jpg)
CesametProducts Affected
• CESAMET
QL Criteria 2 capsules Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
203
![Page 204: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/204.jpg)
CesiaProducts Affected
• CESIA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
204
![Page 205: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/205.jpg)
CetrotideProducts Affected
• CETROTIDE SUBCUTANEOUS* KIT 0.25 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
205
![Page 206: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/206.jpg)
Cevimeline HClProducts Affected
• cevimeline hcl
QL Criteria 3 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
206
![Page 207: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/207.jpg)
ChantixProducts Affected
• CHANTIX
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
207
![Page 208: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/208.jpg)
Chantix Continuing Month PakProducts Affected
• CHANTIX CONTINUING MONTH PAK
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
208
![Page 209: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/209.jpg)
Chantix Starting Month PakProducts Affected
• CHANTIX STARTING MONTH PAK
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
209
![Page 210: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/210.jpg)
ChatealProducts Affected
• CHATEAL
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
210
![Page 211: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/211.jpg)
ChenodalProducts Affected
• CHENODAL
PA Criteria Criteria Details
Covered Uses Cholesterol-type gallstones, Cerebrotendinous Xanthomatosis (CTX)
Exclusion CriteriaIntrahepatic duct calculus, Chronic constipation in patients with cholesterol gallstones, Prophylaxis of recurrent gallstones, Hyperlipidemia, Rheumatoid Arthritis
Required Medical Information
For treatment of cholesterol-type gallstones, documentation of trial and failure of 2 years of generic ursodiol therapy, and documentaion of inability to undergo surgery due to systemic disease or age.
Age Restrictions 18 Years of age or greater
Prescriber Restrictions
Coverage Duration
1 month, extended approval after 3 months based on response and laboratory values
Other Criteria
Notes/References
Revision DatePrior Authorization: April 13, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
211
![Page 212: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/212.jpg)
Chorionic GonadotropinProducts Affected
• chorionic gonadotropin intramuscular*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
212
![Page 213: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/213.jpg)
CialisProducts Affected
• CIALIS ORAL TABLET 5 MG
PA Criteria Criteria Details
Covered Uses Benign Prostatic hyperplasia (BPH)
Exclusion Criteria Use solely for erectile dysfunction.
Required Medical Information
Diagnosis of benign prostatic hyperplasia, a trial and failure of two alpha blockers, and trial and failure of one 5-alpha reductase inhibitor
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References Annual Review: 07/2016
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
213
![Page 214: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/214.jpg)
CimziaProducts Affected
• CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Cimzia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Cimzia.html
QL Criteria 1 kit Per 1 month
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
214
![Page 215: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/215.jpg)
Cimzia PrefilledProducts Affected
• CIMZIA PREFILLED
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Cimzia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Cimzia.html
QL Criteria 1 kit Per 1 month
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
215
![Page 216: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/216.jpg)
Cimzia Starter KitProducts Affected
• CIMZIA STARTER KIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Cimzia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Cimzia.html
QL Criteria 1 kit Per 1 month
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
216
![Page 217: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/217.jpg)
Citalopram HydrobromideProducts Affected
• citalopram hydrobromide oral tablet 10 mg, 20 mg
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
217
![Page 218: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/218.jpg)
Citalopram HydrobromideProducts Affected
• citalopram hydrobromide oral tablet 40 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
218
![Page 219: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/219.jpg)
ClaravisProducts Affected
• CLARAVIS
ST Criteria Documented step through MINOCYCLINE OR DOXYCYCLINE
QL Criteria 2 capsules Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
219
![Page 220: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/220.jpg)
Clever Chek Auto-CodeProducts Affected
• CLEVER CHEK AUTO-CODE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
220
![Page 221: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/221.jpg)
Clever Chek Auto-Code SystemProducts Affected
• CLEVER CHEK AUTO-CODE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
221
![Page 222: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/222.jpg)
Clever Chek Auto-Code TestProducts Affected
• CLEVER CHEK AUTO-CODE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
222
![Page 223: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/223.jpg)
Clever Chek Auto-Code VoiceProducts Affected
• CLEVER CHEK AUTO-CODE VOICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
223
![Page 224: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/224.jpg)
Clever Chek Auto-Code VoiceProducts Affected
• CLEVER CHEK AUTO-CODE VOICE IN VITRO
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
224
![Page 225: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/225.jpg)
Clever Chek TestProducts Affected
• CLEVER CHEK TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
225
![Page 226: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/226.jpg)
Clever Choice Auto-Code SystemProducts Affected
• CLEVER CHOICE AUTO-CODE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
226
![Page 227: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/227.jpg)
Clever Choice Auto-Code TestProducts Affected
• CLEVER CHOICE AUTO-CODE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
227
![Page 228: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/228.jpg)
Clever Choice Micro TestProducts Affected
• CLEVER CHOICE MICRO TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
228
![Page 229: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/229.jpg)
Clever Choice Mini SystemProducts Affected
• CLEVER CHOICE MINI SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
229
![Page 230: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/230.jpg)
Climara ProProducts Affected
• CLIMARA PRO
QL Criteria 1 box (4 patches) Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
230
![Page 231: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/231.jpg)
CloNIDine HCl ERProducts Affected
• clonidine hcl er
ST Criteria Documented step through a STIMULANT
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
231
![Page 232: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/232.jpg)
Clopidogrel BisulfateProducts Affected
• clopidogrel bisulfate
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
232
![Page 233: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/233.jpg)
CloZAPineProducts Affected
• clozapine oral tablet 50 mg, 25 mg • clozapine oral tablet dispersible 25 mg
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
233
![Page 234: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/234.jpg)
CloZAPineProducts Affected
• clozapine oral tablet dispersible 100 mg • clozapine oral tablet 100 mg
QL Criteria 9 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
234
![Page 235: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/235.jpg)
CloZAPineProducts Affected
• clozapine oral tablet dispersible 150 mg, 200 mg
QL Criteria 6 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
235
![Page 236: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/236.jpg)
CloZAPineProducts Affected
• clozapine oral tablet dispersible 12.5 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
236
![Page 237: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/237.jpg)
CloZAPineProducts Affected
• clozapine oral tablet 200 mg
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
237
![Page 238: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/238.jpg)
CoagadexProducts Affected
• COAGADEX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
238
![Page 239: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/239.jpg)
ColchicineProducts Affected
• colchicine oral tablet
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
239
![Page 240: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/240.jpg)
Colyte with Flavor PacksProducts Affected
• COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 227.1 GM
QL Criteria 4 liters Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
240
![Page 241: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/241.jpg)
CombiPatchProducts Affected
• COMBIPATCH
QL Criteria 8 patches Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
241
![Page 242: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/242.jpg)
Cometriq (100 mg Daily Dose)Products Affected
• COMETRIQ (100 MG DAILY DOSE)
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 kits Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
242
![Page 243: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/243.jpg)
Cometriq (140 mg Daily Dose)Products Affected
• COMETRIQ (140 MG DAILY DOSE)
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 EA Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
243
![Page 244: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/244.jpg)
Cometriq (60 mg Daily Dose)Products Affected
• COMETRIQ (60 MG DAILY DOSE)
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 3 kits Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
244
![Page 245: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/245.jpg)
CompleraProducts Affected
• COMPLERA
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
245
![Page 246: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/246.jpg)
Control ASTProducts Affected
• CONTROL AST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
246
![Page 247: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/247.jpg)
Control TestProducts Affected
• CONTROL TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
247
![Page 248: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/248.jpg)
CopaxoneProducts Affected
• COPAXONE SUBCUTANEOUS* 40 MG/ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
248
![Page 249: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/249.jpg)
CopaxoneProducts Affected
• COPAXONE SUBCUTANEOUS* 20 MG/ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
249
![Page 250: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/250.jpg)
CordranProducts Affected
• CORDRAN EXTERNAL TAPE
QL Criteria 1 roll Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
250
![Page 251: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/251.jpg)
Coreg CRProducts Affected
• COREG CR
ST Criteria Documented step through CARVEDILOL
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
251
![Page 252: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/252.jpg)
CorifactProducts Affected
• CORIFACT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
252
![Page 253: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/253.jpg)
Cosopt PFProducts Affected
• COSOPT PF
ST Criteria Documented step through DORZOLAMIDE/TIMOLOL
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
253
![Page 254: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/254.jpg)
CreonProducts Affected
• CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 6000 UNIT
PA Criteria Criteria Details
Covered Uses Exocrine pancreatic Insufficiency
Exclusion CriteriaUses not approved by the FDA, uses unapproved and not supported by the literature or evidence as an accepted off-label use. (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Diagnosis of exocrine pancreatic insufficiency due to cystic fibrosis or other conditions and a documented trial of two weeks of Zenpep.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References Annual Review: 07/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
254
![Page 255: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/255.jpg)
CrinoneProducts Affected
• CRINONE
PA Criteria Criteria Details
Covered UsesART (Assisted Reproductive Technology), secondary amenorrhea, prevention of early pregnancy failure
Exclusion Criteria
Crinone, Endometrin, First Progesterone VGS is NOT covered for uses not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Crinone, Endometrin, First Progesterone VGS are covered for members who meet the following criteria: (1) ART (Assisted Reproductive Technology): Crinone 8%, Endometrin, First Progesterone VGS: Documented diagnosis of progesterone deficiency in an infertile woman and member must have infertility coverage, or (2) Secondary amenorrhea: Crinone 4%, Crinone 8%: Documented diagnosis of progesterone deficiency in an infertile woman, and Crinone 8% is only for use in women who have failed to respond to treatment with Crinone 4%, and member must have infertility coverage, or (3) Prevention of early pregnancy failure
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
255
![Page 256: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/256.jpg)
Cryselle-28Products Affected
• CRYSELLE-28
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
256
![Page 257: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/257.jpg)
CuvposaProducts Affected
• CUVPOSA
PA Criteria Criteria Details
Covered Uses neurologic conditions associated with drooling (e.g. cerebral palsy)
Exclusion Criteria
Required Medical Information
Documentaion of neurologic conditions associated with drooling (e.g. cerebral palsy) to reduce severe chronic drooling
Age Restrictions 3 years to 16 years
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 21, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
257
![Page 258: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/258.jpg)
Cyclafem 1/35Products Affected
• CYCLAFEM 1/35
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
258
![Page 259: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/259.jpg)
CyclessaProducts Affected
• CYCLESSA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
259
![Page 260: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/260.jpg)
CyclosetProducts Affected
• CYCLOSET
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
260
![Page 261: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/261.jpg)
DacogenProducts Affected
• DACOGEN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
261
![Page 262: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/262.jpg)
DaklinzaProducts Affected
• DAKLINZA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
262
![Page 263: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/263.jpg)
DaklinzaProducts Affected
• DAKLINZA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
QL Criteria 1 EA Per 1 Day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
263
![Page 264: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/264.jpg)
DalirespProducts Affected
• DALIRESP
PA Criteria Criteria Details
Covered Uses Severe COPD
Exclusion Criteria Use for relief of acute bronchospasm
Required Medical Information
Diagnosis of severe COPD (FEV1 less than 50% predicted) associated with chronic bronchitis and at least one documented COPD exacerbation in the previous year, and an inadequate response or contraindication to a combination or single agent long-acting beta 2-agonist agent and Spiriva/Tudorza. An inadequate response to standard therapy shall include any exacerbation event requiring intervention with systemic glucocorticosteroids or hospitalization.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
264
![Page 265: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/265.jpg)
Darifenacin Hydrobromide ERProducts Affected
• darifenacin hydrobromide er
ST Criteria Documented step through OXYBUTYNIN or TROSPIUM AND VESICARE or MYRBETRIQ
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
265
![Page 266: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/266.jpg)
Dasetta 1/35Products Affected
• DASETTA 1/35
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
266
![Page 267: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/267.jpg)
DayseeProducts Affected
• DAYSEE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
267
![Page 268: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/268.jpg)
DaytranaProducts Affected
• DAYTRANA
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 1 patch Per 1 day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
268
![Page 269: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/269.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
269
![Page 270: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/270.jpg)
DeblitaneProducts Affected
• DEBLITANE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
270
![Page 271: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/271.jpg)
DecitabineProducts Affected
• decitabine
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
271
![Page 272: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/272.jpg)
DelzicolProducts Affected
• DELZICOL
ST Criteria Documented failure, contraindication or intolerance to Apriso
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
272
![Page 273: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/273.jpg)
DenavirProducts Affected
• DENAVIR
ST Criteria Documented step through ORAL ACYCLOVIR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
273
![Page 274: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/274.jpg)
Depo-ProveraProducts Affected
• DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 150 MG/ML
QL Criteria 1 syringe Per 90 dayss
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
274
![Page 275: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/275.jpg)
Depo-SubQ Provera 104Products Affected
• DEPO-SUBQ PROVERA 104 SUBCUTANEOUS* SUSPENSION
PA Criteria Criteria Details
Covered Uses Contraception/hormone therapy
Exclusion Criteria
Required Medical Information
A documented contraindication or intolerance or allergy or failure of an adequate trial of one month of one preferred oral generic alternative or a documented mental or physical handicap preventing the reasonable use of an oral contraceptive.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 1 syringe Per 90 dayss
Notes/References Annual Review: 08/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
275
![Page 276: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/276.jpg)
DescovyProducts Affected
• DESCOVY
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/antiviral_hiv.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
276
![Page 277: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/277.jpg)
DesloratadineProducts Affected
• desloratadine
ST Criteria Documented step through TWO of the following: CLARITIN OTC, ZYRTEC OTC, ALLEGRA OTC
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
277
![Page 278: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/278.jpg)
DesogenProducts Affected
• DESOGEN
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
278
![Page 279: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/279.jpg)
Dexcom G4 Platinum ReceiverProducts Affected
• DEXCOM G4 PLATINUM RECEIVER
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
279
![Page 280: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/280.jpg)
Dexcom G4 Platinum Sensor KitProducts Affected
• DEXCOM G4 PLATINUM SENSOR KIT
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
280
![Page 281: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/281.jpg)
Dexcom G4 Platinum TransmitterProducts Affected
• DEXCOM G4 PLATINUM TRANSMITTER
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
281
![Page 282: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/282.jpg)
Dexcom G4 SensorProducts Affected
• DEXCOM G4 SENSOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
282
![Page 283: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/283.jpg)
DexilantProducts Affected
• DEXILANT
PA Criteria Criteria Details
Covered Uses
Diagnosis of Zollinger-Ellison syndrome, Uncomplicated gastroesophageal reflux desease (Gerd) with breakthrough symptoms, Complicated GERD and other higher risk conditions such as feflux-associated laryngitis, recent gastroinestinal bleed, grade 3 or 4 erosive esophagitis, or GERD exacerbated asthma.
Exclusion Criteria
Non-Covered uses include uses not approved by the FDA, or if use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use). Quantity levels exceeding the quantity limitations on PPIs, Dexilant dosing exceeding 60mg/day
Required Medical Information
Rabeprazole up to 20 mg/day, Dexilant up to 60 mg/day, and Nexium up to 40 mg/day are available with prior-authorization when the following criteria is met: Step through Prilosec OTC/omeprazole, Prevacid 24H OTC, and pantoprazole. High Dose Nexium, Rabeprazole and Prevacid solutabs are available with prior-authorization when the following criteria is met: Nexium up to 80mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Rabeprazole up to 40mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Prevacid solutabs up to 60mg/day for members greater than 1 year old with documentation of: inability to swallow tablets/capsules and step through ONE of the following: 80mg/day of omeprazole (capsules may be opened and sprinkled on 1 tablespoon of applesauce), or 60mg/day of Prevacid 24H OTC (capsule may be opened and sprinkled on 1 tablespoon of applesauce, Ensure pudding, cottage cheese, yogurt, or strained pears, or emptied into 60mL of apple juice, orange juice, or tomato juice )
Age Restrictions
Prescriber Restrictions
Coverage Duration
Short Term course of high dose PPI 3-6 months. Long term course up to 1 Year.
2016 Innovation Health Leap Drug GuideLast update 12/2016
283
![Page 284: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/284.jpg)
PA Criteria Criteria Details
Other Criteria
A step through one of these high dose therapies (80mg/day of Prilosec OTC/omeprazole or pantoprazole, OR 60mg/day of Prevacid 24H OTC) is required even if the member was previously approved for Rabeprazole, Prevacid solutabs, or Nexium at standard dosing. Exceptions may be considered if there is documentation of intolerance, e.g., side-effects or allergies to Prilosec OTC/omeprazole, pantoprazole, and Prevacid 24H OTC.
QL Criteria 1 capsule Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
284
![Page 285: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/285.jpg)
Dexmethylphenidate HClProducts Affected
• dexmethylphenidate hcl
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
285
![Page 286: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/286.jpg)
Dexmethylphenidate HCl ERProducts Affected
• dexmethylphenidate hcl er
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
286
![Page 287: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/287.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
287
![Page 288: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/288.jpg)
Dextroamphetamine SulfateProducts Affected
• dextroamphetamine sulfate oral solution
QL Criteria 40 milliliters Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
288
![Page 289: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/289.jpg)
Dextroamphetamine SulfateProducts Affected
• dextroamphetamine sulfate oral tablet
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
289
![Page 290: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/290.jpg)
Dextroamphetamine Sulfate ERProducts Affected
• dextroamphetamine sulfate er
QL Criteria 4 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
290
![Page 291: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/291.jpg)
DiazepamProducts Affected
• diazepam gel
QL Criteria 1 box Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
291
![Page 292: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/292.jpg)
Diclofenac SodiumProducts Affected
• diclofenac sodium transdermal gel 1 %
QL Criteria 200 grams Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
292
![Page 293: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/293.jpg)
DificidProducts Affected
• DIFICID
PA Criteria Criteria Details
Covered Uses
Exclusion CriteriaInitial episodes of mild, moderate, or severe CDI.Severe complicated CDI (i.e. hypotension, ileus, megacolon, or shock).
Required Medical Information
Step through two courses of antibiotics: metronidazole and/or oral vancomycin
Age Restrictions
Prescriber Restrictions
18 years old or greater
Coverage Duration
10 Days of therapy
Other Criteria
QL Criteria 20 tablets Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
293
![Page 294: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/294.jpg)
Diltiazem CDProducts Affected
• diltiazem cd oral capsule extended release 24 hour 240 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
294
![Page 295: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/295.jpg)
Diltiazem CDProducts Affected
• diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
295
![Page 296: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/296.jpg)
Diltiazem HCl ERProducts Affected
• diltiazem hcl er oral capsule extended release 24 hour 180 mg, 120 mg
• diltiazem hcl er oral capsule extended release 12 hour 120 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
296
![Page 297: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/297.jpg)
Diltiazem HCl ERProducts Affected
• diltiazem hcl er oral capsule extended release 24 hour 240 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
297
![Page 298: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/298.jpg)
Diltiazem HCl ER BeadsProducts Affected
• diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 300 mg, 360 mg, 120 mg, 420 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
298
![Page 299: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/299.jpg)
Diltiazem HCl ER BeadsProducts Affected
• diltiazem hcl er beads oral capsule extended release 24 hour 240 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
299
![Page 300: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/300.jpg)
Diltiazem HCl ER Coated BeadsProducts Affected
• diltiazem hcl er coated beads oral capsule extended release 24 hour 300 mg, 180 mg, 120 mg, 360 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
300
![Page 301: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/301.jpg)
Diltiazem HCl ER Coated BeadsProducts Affected
• diltiazem hcl er coated beads oral capsule extended release 24 hour 240 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
301
![Page 302: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/302.jpg)
Dilt-XRProducts Affected
• dilt-xr oral capsule extended release 24 hour180 mg, 120 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
302
![Page 303: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/303.jpg)
Dilt-XRProducts Affected
• dilt-xr oral capsule extended release 24 hour240 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
303
![Page 304: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/304.jpg)
DipentumProducts Affected
• DIPENTUM
ST Criteria Documented failure, contraindication or intolerance to Apriso
QL Criteria 4 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
304
![Page 305: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/305.jpg)
Donepezil HClProducts Affected
• donepezil hcl oral tablet 23 mg
ST Criteria Documented step through DONEPEZIL 10MG
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
305
![Page 306: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/306.jpg)
Donepezil HClProducts Affected
• donepezil hcl oral tablet 10 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
306
![Page 307: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/307.jpg)
DronabinolProducts Affected
• dronabinol
PA Criteria Criteria Details
Covered UsesAnorexia associated with weight loss in patients with AIDS, Chemotherapy-induced nausea and vomiting
Exclusion Criteria Multiple sclerosis (spasticity), Fibromyalgia (Neuropathic Pain)
Required Medical Information
A diagnosis of anorexia associated with weight loss in patients with AIDS or for the treatment of chemotherapy induced nausea and vomiting who have failed to respond to conventional antiemetic therapies (such as prochlorperazine, chlorpromazine, haloperidol and metoclopramide)
Age Restrictions
Prescriber Restrictions
Coverage Duration
Initial: 6 months. Continuation: 12 months if demonstrated adequate response to therapy.
Other Criteria
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
307
![Page 308: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/308.jpg)
Drospiren-Eth Estrad-LevomefolProducts Affected
• drospiren-eth estrad-levomefol
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
308
![Page 309: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/309.jpg)
Drospirenone-Ethinyl EstradiolProducts Affected
• drospirenone-ethinyl estradiol oral tablet3-0.03 mg
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
309
![Page 310: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/310.jpg)
DuleraProducts Affected
• DULERA
QL Criteria 1 inhaler Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
310
![Page 311: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/311.jpg)
DULoxetine HClProducts Affected
• duloxetine hcl oral capsule delayed release particles 30 mg, 60 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
311
![Page 312: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/312.jpg)
DULoxetine HClProducts Affected
• duloxetine hcl oral capsule delayed release particles 40 mg
QL Criteria 1 cap Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
312
![Page 313: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/313.jpg)
DULoxetine HClProducts Affected
• duloxetine hcl oral capsule delayed release particles 20 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
313
![Page 314: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/314.jpg)
DutasterideProducts Affected
• dutasteride
ST Criteria Documented step through FINASTERIDE
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
314
![Page 315: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/315.jpg)
Easy Plus II Glucose SystemProducts Affected
• easy plus ii glucose system
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
315
![Page 316: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/316.jpg)
Easy Plus II Glucose TestProducts Affected
• easy plus ii glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
316
![Page 317: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/317.jpg)
Easy Step Glucose MonitorProducts Affected
• EASY STEP GLUCOSE MONITOR DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
317
![Page 318: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/318.jpg)
Easy Step TestProducts Affected
• EASY STEP TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
318
![Page 319: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/319.jpg)
Easy Talk Blood Glucose SystemProducts Affected
• easy talk blood glucose system device
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
319
![Page 320: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/320.jpg)
Easy Talk Blood Glucose TestProducts Affected
• easy talk blood glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
320
![Page 321: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/321.jpg)
Easy Touch TestProducts Affected
• EASY TOUCH TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
321
![Page 322: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/322.jpg)
Easy Trak Blood Glucose TestProducts Affected
• easy trak blood glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
322
![Page 323: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/323.jpg)
EasyGlucoProducts Affected
• EASYGLUCO IN VITRO
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
323
![Page 324: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/324.jpg)
EasyMax 15 TestProducts Affected
• EASYMAX 15 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
324
![Page 325: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/325.jpg)
EasyMax L Blood GlucoseProducts Affected
• EASYMAX L BLOOD GLUCOSE DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
325
![Page 326: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/326.jpg)
EasyMax N Blood GlucoseProducts Affected
• EASYMAX N BLOOD GLUCOSE DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
326
![Page 327: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/327.jpg)
EasyMax NG Blood GlucoseProducts Affected
• EASYMAX NG BLOOD GLUCOSE DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
327
![Page 328: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/328.jpg)
EASYMax TestProducts Affected
• EASYMAX TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
328
![Page 329: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/329.jpg)
EasyMax V Blood GlucoseProducts Affected
• EASYMAX V BLOOD GLUCOSE DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
329
![Page 330: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/330.jpg)
EasyMax V2 Blood GlucoseProducts Affected
• EASYMAX V2 BLOOD GLUCOSE DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
330
![Page 331: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/331.jpg)
EasyPlus Blood Glucose TestProducts Affected
• easyplus blood glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
331
![Page 332: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/332.jpg)
EasyPRO PlusProducts Affected
• EASYPRO PLUS IN VITRO
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
332
![Page 333: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/333.jpg)
EdarbiProducts Affected
• EDARBI
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
333
![Page 334: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/334.jpg)
EdarbyclorProducts Affected
• EDARBYCLOR
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
334
![Page 335: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/335.jpg)
EdurantProducts Affected
• EDURANT
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
335
![Page 336: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/336.jpg)
EffientProducts Affected
• EFFIENT
ST Criteria Documented step through CLOPIDOGREL
QL Criteria 1 tablet Per 1 day
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
336
![Page 337: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/337.jpg)
EgriftaProducts Affected
• EGRIFTA SUBCUTANEOUS* SOLUTION RECONSTITUTED 2 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Antidotes.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
337
![Page 338: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/338.jpg)
ElapraseProducts Affected
• ELAPRASE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
338
![Page 339: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/339.jpg)
ElelysoProducts Affected
• ELELYSO
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
339
![Page 340: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/340.jpg)
Element PlusProducts Affected
• ELEMENT PLUS
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
340
![Page 341: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/341.jpg)
Element TestProducts Affected
• ELEMENT TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
341
![Page 342: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/342.jpg)
ElidelProducts Affected
• ELIDEL
PA Criteria Criteria Details
Covered Uses Atopic Dermatitis
Exclusion Criteria
Required Medical Information
FOR CHILDREN LESS THAN 2 YEARS OF AGE: Covered for the treatment of mild to moderate atopic dermatitis (eczema) for short-term use (up to 3 months). FOR ADULTS: A documented diagnosis of atopic dermatitis (eczema) and the patient has a documented failure of an adequate trial of 2 weeks (14 days) of one preferred alternative topical corticosteroid indicated for the patient's condition or the patient is being treated for atopic dermatitis (eczema) in an area at high risk for skin atrophy such as face, eyelids, or genital areas.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year (3 months if less than 2 years old)
Other Criteria
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
342
![Page 343: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/343.jpg)
ElinestProducts Affected
• ELINEST
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
343
![Page 344: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/344.jpg)
EliquisProducts Affected
• ELIQUIS
ST Criteria A documented step through Xarelto and Pradaxa
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
344
![Page 345: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/345.jpg)
EllaProducts Affected
• ELLA
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
345
![Page 346: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/346.jpg)
EloctateProducts Affected
• ELOCTATE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
346
![Page 347: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/347.jpg)
EmbedaProducts Affected
• EMBEDA
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
QL Criteria 2 capsules Per 1 day
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
347
![Page 348: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/348.jpg)
Embrace Blood Glucose MonitorProducts Affected
• EMBRACE BLOOD GLUCOSE MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
348
![Page 349: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/349.jpg)
Embrace Blood Glucose TestProducts Affected
• EMBRACE BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
349
![Page 350: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/350.jpg)
EmendProducts Affected
• EMEND ORAL CAPSULE 80 & 125 MG
QL Criteria 3 tri-packs Per 30 months
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
350
![Page 351: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/351.jpg)
EmendProducts Affected
• EMEND ORAL CAPSULE 125 MG, 80 MG, 40 MG
QL Criteria 9 capsules Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
351
![Page 352: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/352.jpg)
EmoquetteProducts Affected
• EMOQUETTE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
352
![Page 353: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/353.jpg)
EmsamProducts Affected
• EMSAM
PA Criteria Criteria Details
Covered Uses Major Dispressive Disorder (MDD)
Exclusion CriteriaPatients taking products containing venlafaxine concomitantly, patients taking MAOIs concomitantly, for use in pediatrics.
Required Medical Information
Patient has documented failure or unresponsiveness to THREE different antidepressants from at least two different therapeutic subclasses, or patient is a new member and has been receiving Emsam therapy for more than 4 weeks.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaExamples of antidepressant trials from unique Therapeutic Subclass include SSRIs, SNRIs, NDRIs, TCAs, tetracyclic antidepressants, and MAOIs
QL Criteria 1 patch Per 1 day
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
353
![Page 354: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/354.jpg)
EmtrivaProducts Affected
• EMTRIVA ORAL CAPSULE
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
354
![Page 355: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/355.jpg)
EnbrelProducts Affected
• ENBREL SUBCUTANEOUS* 50 MG/ML • ENBREL SUBCUTANEOUS* KIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 8 syringes Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
355
![Page 356: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/356.jpg)
EnbrelProducts Affected
• ENBREL SUBCUTANEOUS* 25 MG/0.5ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 syringes Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
356
![Page 357: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/357.jpg)
Enbrel SureClickProducts Affected
• ENBREL SURECLICK SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 8 syringes Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
357
![Page 358: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/358.jpg)
EndometrinProducts Affected
• ENDOMETRIN
PA Criteria Criteria Details
Covered UsesART (Assisted Reproductive Technology), secondary amenorrhea, prevention of early pregnancy failure
Exclusion Criteria
Crinone, Endometrin, First Progesterone VGS is NOT covered for uses not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Crinone, Endometrin, First Progesterone VGS are covered for members who meet the following criteria: (1) ART (Assisted Reproductive Technology): Crinone 8%, Endometrin, First Progesterone VGS: Documented diagnosis of progesterone deficiency in an infertile woman and member must have infertility coverage, or (2) Secondary amenorrhea: Crinone 4%, Crinone 8%: Documented diagnosis of progesterone deficiency in an infertile woman, and Crinone 8% is only for use in women who have failed to respond to treatment with Crinone 4%, and member must have infertility coverage, or (3) Prevention of early pregnancy failure
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
358
![Page 359: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/359.jpg)
EnjuviaProducts Affected
• ENJUVIA ORAL TABLET 0.9 MG, 0.45 MG, 0.625 MG, 0.3 MG
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
359
![Page 360: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/360.jpg)
EnjuviaProducts Affected
• ENJUVIA ORAL TABLET 1.25 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
360
![Page 361: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/361.jpg)
Enoxaparin SodiumProducts Affected
• enoxaparin sodium
QL Criteria 2 syringes Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
361
![Page 362: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/362.jpg)
Enpresse-28Products Affected
• ENPRESSE-28
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
362
![Page 363: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/363.jpg)
EntecavirProducts Affected
• entecavir oral tablet 1 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
363
![Page 364: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/364.jpg)
EpclusaProducts Affected
• EPCLUSA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
364
![Page 365: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/365.jpg)
EpiduoProducts Affected
• EPIDUO
ST Criteria Documented step through TRETINOIN
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
365
![Page 366: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/366.jpg)
Epiduo ForteProducts Affected
• EPIDUO FORTE
ST Criteria Documented step through TRETINOIN
QL Criteria 1 pump Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
366
![Page 367: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/367.jpg)
EPINEPHrineProducts Affected
• epinephrine injection 0.3 mg/0.3ml, 0.15 mg/0.15ml
QL Criteria 2 pens Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
367
![Page 368: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/368.jpg)
EpiPen 2-PakProducts Affected
• EPIPEN 2-PAK INJECTION
QL Criteria 2 pens Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
368
![Page 369: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/369.jpg)
EpogenProducts Affected
• EPOGEN INJECTION SOLUTION 3000 UNIT/ML, 20000 UNIT/ML, 4000 UNIT/ML, 10000 UNIT/ML, 2000 UNIT/ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Erythropoiesis_Stimulating_Agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
369
![Page 370: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/370.jpg)
Epoprostenol SodiumProducts Affected
• epoprostenol sodium
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
370
![Page 371: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/371.jpg)
Eprosartan MesylateProducts Affected
• eprosartan mesylate
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
371
![Page 372: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/372.jpg)
ErivedgeProducts Affected
• ERIVEDGE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
372
![Page 373: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/373.jpg)
ErrinProducts Affected
• ERRIN
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
373
![Page 374: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/374.jpg)
Escitalopram OxalateProducts Affected
• escitalopram oxalate oral tablet 5 mg, 20 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
374
![Page 375: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/375.jpg)
Escitalopram OxalateProducts Affected
• escitalopram oxalate oral tablet 10 mg
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
375
![Page 376: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/376.jpg)
Esomeprazole MagnesiumProducts Affected
• esomeprazole magnesium
PA Criteria Criteria Details
Covered Uses
Diagnosis of Zollinger-Ellison syndrome, Uncomplicated gastroesophageal reflux desease (Gerd) with breakthrough symptoms, Complicated GERD and other higher risk conditions such as feflux-associated laryngitis, recent gastroinestinal bleed, grade 3 or 4 erosive esophagitis, or GERD exacerbated asthma.
Exclusion Criteria
Non-Covered uses include uses not approved by the FDA, or if use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use). Quantity levels exceeding the quantity limitations on PPIs, Dexilant dosing exceeding 60mg/day
Required Medical Information
Rabeprazole up to 20 mg/day, Dexilant up to 60 mg/day, and Nexium up to 40 mg/day are available with prior-authorization when the following criteria is met: Step through Prilosec OTC/omeprazole, Prevacid 24H OTC, and pantoprazole. High Dose Nexium, Rabeprazole and Prevacid solutabs are available with prior-authorization when the following criteria is met: Nexium up to 80mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Rabeprazole up to 40mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Prevacid solutabs up to 60mg/day for members greater than 1 year old with documentation of: inability to swallow tablets/capsules and step through ONE of the following: 80mg/day of omeprazole (capsules may be opened and sprinkled on 1 tablespoon of applesauce), or 60mg/day of Prevacid 24H OTC (capsule may be opened and sprinkled on 1 tablespoon of applesauce, Ensure pudding, cottage cheese, yogurt, or strained pears, or emptied into 60mL of apple juice, orange juice, or tomato juice )
Age Restrictions
Prescriber Restrictions
Coverage Duration
Short Term course of high dose PPI 3-6 months. Long term course up to 1 Year.
2016 Innovation Health Leap Drug GuideLast update 12/2016
376
![Page 377: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/377.jpg)
PA Criteria Criteria Details
Other Criteria
A step through one of these high dose therapies (80mg/day of Prilosec OTC/omeprazole or pantoprazole, OR 60mg/day of Prevacid 24H OTC) is required even if the member was previously approved for Rabeprazole, Prevacid solutabs, or Nexium at standard dosing. Exceptions may be considered if there is documentation of intolerance, e.g., side-effects or allergies to Prilosec OTC/omeprazole, pantoprazole, and Prevacid 24H OTC.
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
377
![Page 378: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/378.jpg)
EstradiolProducts Affected
• estradiol transdermal patch weekly
QL Criteria 1 box (4 patches) Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
378
![Page 379: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/379.jpg)
EstradiolProducts Affected
• estradiol transdermal patch biweekly
QL Criteria 8 patches Per 28 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
379
![Page 380: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/380.jpg)
Estradiol-Norethindrone AcetProducts Affected
• estradiol-norethindrone acet
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
380
![Page 381: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/381.jpg)
EstrogelProducts Affected
• ESTROGEL
QL Criteria 50 grams Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
381
![Page 382: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/382.jpg)
Estrostep FeProducts Affected
• ESTROSTEP FE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
382
![Page 383: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/383.jpg)
EszopicloneProducts Affected
• eszopiclone
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
383
![Page 384: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/384.jpg)
EvamistProducts Affected
• EVAMIST
QL Criteria 2 bottles Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
384
![Page 385: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/385.jpg)
EvenCare + Blood Glucose TestProducts Affected
• EVENCARE + BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
385
![Page 386: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/386.jpg)
EvenCare Blood Glucose TestProducts Affected
• EVENCARE BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
386
![Page 387: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/387.jpg)
EvenCare G2 MonitorProducts Affected
• EVENCARE G2 MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
387
![Page 388: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/388.jpg)
EvenCare G2 TestProducts Affected
• EVENCARE G2 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
388
![Page 389: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/389.jpg)
EvenCare G3 MonitorProducts Affected
• EVENCARE G3 MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
389
![Page 390: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/390.jpg)
EvenCare G3 TestProducts Affected
• EVENCARE G3 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
390
![Page 391: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/391.jpg)
Evolution AutocodeProducts Affected
• EVOLUTION AUTOCODE IN VITRO
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
391
![Page 392: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/392.jpg)
Evolution AutocodeProducts Affected
• EVOLUTION AUTOCODE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
392
![Page 393: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/393.jpg)
ExjadeProducts Affected
• EXJADE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Antidotes.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
393
![Page 394: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/394.jpg)
ExtaviaProducts Affected
• EXTAVIA SUBCUTANEOUS* KIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
QL Criteria 1 box (15 vials) Per 1 month
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
394
![Page 395: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/395.jpg)
Ez Smart Blood Glucose TestProducts Affected
• EZ SMART BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
395
![Page 396: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/396.jpg)
Ez Smart Monitoring SystemProducts Affected
• EZ SMART MONITORING SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
396
![Page 397: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/397.jpg)
Ez Smart Plus Glucose TestProducts Affected
• EZ SMART PLUS GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
397
![Page 398: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/398.jpg)
Ez Smart Plus Monitoring SysProducts Affected
• EZ SMART PLUS MONITORING SYS
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
398
![Page 399: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/399.jpg)
FabrazymeProducts Affected
• FABRAZYME
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
399
![Page 400: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/400.jpg)
FalminaProducts Affected
• FALMINA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
400
![Page 401: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/401.jpg)
FamciclovirProducts Affected
• famciclovir oral tablet 125 mg, 250 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
401
![Page 402: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/402.jpg)
FamciclovirProducts Affected
• famciclovir oral tablet 500 mg
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
402
![Page 403: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/403.jpg)
FanaptProducts Affected
• FANAPT
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
403
![Page 404: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/404.jpg)
Fanapt Titration PackProducts Affected
• FANAPT TITRATION PACK
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
404
![Page 405: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/405.jpg)
Felodipine ERProducts Affected
• felodipine er
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
405
![Page 406: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/406.jpg)
Femcon FeProducts Affected
• FEMCON FE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
406
![Page 407: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/407.jpg)
Femhrt Low DoseProducts Affected
• FEMHRT LOW DOSE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
407
![Page 408: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/408.jpg)
FemringProducts Affected
• FEMRING
QL Criteria 1 ring Per 90 dayss
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
408
![Page 409: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/409.jpg)
FenofibrateProducts Affected
• fenofibrate oral
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
409
![Page 410: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/410.jpg)
FenofibrateProducts Affected
• fenofibrate oral
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
410
![Page 411: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/411.jpg)
Fenofibrate MicronizedProducts Affected
• fenofibrate micronized
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
411
![Page 412: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/412.jpg)
Fenofibric AcidProducts Affected
• fenofibric acid oral tablet
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
412
![Page 413: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/413.jpg)
FentaNYLProducts Affected
• fentanyl
PA Criteria Criteria Details
Covered Uses moderate to severe pain
Exclusion Criteria
Required Medical Information
Documented diagnosis of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 20 patches Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
413
![Page 414: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/414.jpg)
FentaNYLProducts Affected
• fentanyl
PA Criteria Criteria Details
Covered Uses moderate to severe pain
Exclusion Criteria
Required Medical Information
Documented diagnosis of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 20 patches Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
414
![Page 415: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/415.jpg)
FentaNYL CitrateProducts Affected
• fentanyl citrate buccal
PA Criteria Criteria Details
Covered Uses Pain due to malignant diagnosis only
Exclusion CriteriaNon-malignant pain, management of acute or postoperative or in patients not taking chronic opiates or not tolerant to opioid therapy.
Required Medical Information
Fentanyl citrate is covered for members with pain due to malignant diagnosis only, and who are already receiving and are tolerant to opioid therapy and who are intolerant of two (2) other immediate-release opioids including morphine, hydrocodone, oxycodone, or hydromorphone. (Patients who are considered opioid tolerant are those who are taking at least 60 mg morphine/day, 25 mcg transdermal fentanyl/hour, or an equianalgesic dose of another opioid for at least a week).
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 months
Other Criteria
QL Criteria 4 lozenges Per 1 day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
415
![Page 416: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/416.jpg)
FerriproxProducts Affected
• FERRIPROX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Antidotes.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
416
![Page 417: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/417.jpg)
Fifty50 Glucose Test 2.0Products Affected
• FIFTY50 GLUCOSE TEST 2.0
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
417
![Page 418: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/418.jpg)
FirazyrProducts Affected
• FIRAZYR
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/hereditary_angioedema.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 3 syringes Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
418
![Page 419: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/419.jpg)
First-Progesterone VGS 100Products Affected
• FIRST-PROGESTERONE VGS 100
PA Criteria Criteria Details
Covered UsesART (Assisted Reproductive Technology), secondary amenorrhea, prevention of early pregnancy failure
Exclusion Criteria
Crinone, Endometrin, First Progesterone VGS is NOT covered for uses not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Crinone, Endometrin, First Progesterone VGS are covered for members who meet the following criteria: (1) ART (Assisted Reproductive Technology): Crinone 8%, Endometrin, First Progesterone VGS: Documented diagnosis of progesterone deficiency in an infertile woman and member must have infertility coverage, or (2) Secondary amenorrhea: Crinone 4%, Crinone 8%: Documented diagnosis of progesterone deficiency in an infertile woman, and Crinone 8% is only for use in women who have failed to respond to treatment with Crinone 4%, and member must have infertility coverage, or (3) Prevention of early pregnancy failure
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
419
![Page 420: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/420.jpg)
First-Progesterone VGS 200Products Affected
• FIRST-PROGESTERONE VGS 200
PA Criteria Criteria Details
Covered UsesART (Assisted Reproductive Technology), secondary amenorrhea, prevention of early pregnancy failure
Exclusion Criteria
Crinone, Endometrin, First Progesterone VGS is NOT covered for uses not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Crinone, Endometrin, First Progesterone VGS are covered for members who meet the following criteria: (1) ART (Assisted Reproductive Technology): Crinone 8%, Endometrin, First Progesterone VGS: Documented diagnosis of progesterone deficiency in an infertile woman and member must have infertility coverage, or (2) Secondary amenorrhea: Crinone 4%, Crinone 8%: Documented diagnosis of progesterone deficiency in an infertile woman, and Crinone 8% is only for use in women who have failed to respond to treatment with Crinone 4%, and member must have infertility coverage, or (3) Prevention of early pregnancy failure
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
420
![Page 421: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/421.jpg)
First-Progesterone VGS 25Products Affected
• FIRST-PROGESTERONE VGS 25
PA Criteria Criteria Details
Covered UsesART (Assisted Reproductive Technology), secondary amenorrhea, prevention of early pregnancy failure
Exclusion Criteria
Crinone, Endometrin, First Progesterone VGS is NOT covered for uses not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Crinone, Endometrin, First Progesterone VGS are covered for members who meet the following criteria: (1) ART (Assisted Reproductive Technology): Crinone 8%, Endometrin, First Progesterone VGS: Documented diagnosis of progesterone deficiency in an infertile woman and member must have infertility coverage, or (2) Secondary amenorrhea: Crinone 4%, Crinone 8%: Documented diagnosis of progesterone deficiency in an infertile woman, and Crinone 8% is only for use in women who have failed to respond to treatment with Crinone 4%, and member must have infertility coverage, or (3) Prevention of early pregnancy failure
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
421
![Page 422: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/422.jpg)
First-Progesterone VGS 400Products Affected
• FIRST-PROGESTERONE VGS 400
PA Criteria Criteria Details
Covered UsesART (Assisted Reproductive Technology), secondary amenorrhea, prevention of early pregnancy failure
Exclusion Criteria
Crinone, Endometrin, First Progesterone VGS is NOT covered for uses not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Crinone, Endometrin, First Progesterone VGS are covered for members who meet the following criteria: (1) ART (Assisted Reproductive Technology): Crinone 8%, Endometrin, First Progesterone VGS: Documented diagnosis of progesterone deficiency in an infertile woman and member must have infertility coverage, or (2) Secondary amenorrhea: Crinone 4%, Crinone 8%: Documented diagnosis of progesterone deficiency in an infertile woman, and Crinone 8% is only for use in women who have failed to respond to treatment with Crinone 4%, and member must have infertility coverage, or (3) Prevention of early pregnancy failure
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
422
![Page 423: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/423.jpg)
First-Progesterone VGS 50Products Affected
• FIRST-PROGESTERONE VGS 50
PA Criteria Criteria Details
Covered UsesART (Assisted Reproductive Technology), secondary amenorrhea, prevention of early pregnancy failure
Exclusion Criteria
Crinone, Endometrin, First Progesterone VGS is NOT covered for uses not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Crinone, Endometrin, First Progesterone VGS are covered for members who meet the following criteria: (1) ART (Assisted Reproductive Technology): Crinone 8%, Endometrin, First Progesterone VGS: Documented diagnosis of progesterone deficiency in an infertile woman and member must have infertility coverage, or (2) Secondary amenorrhea: Crinone 4%, Crinone 8%: Documented diagnosis of progesterone deficiency in an infertile woman, and Crinone 8% is only for use in women who have failed to respond to treatment with Crinone 4%, and member must have infertility coverage, or (3) Prevention of early pregnancy failure
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
423
![Page 424: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/424.jpg)
Flebogamma DIFProducts Affected
• FLEBOGAMMA DIF
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
424
![Page 425: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/425.jpg)
Flovent DiskusProducts Affected
• FLOVENT DISKUS
ST Criteria Documented step through QVAR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
425
![Page 426: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/426.jpg)
Flovent HFAProducts Affected
• FLOVENT HFA
ST Criteria Documented step through QVAR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
426
![Page 427: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/427.jpg)
FlunisolideProducts Affected
• flunisolide nasal solution 25 mcg/act (0.025%)
QL Criteria 2 bottles Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
427
![Page 428: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/428.jpg)
FLUoxetine HClProducts Affected
• fluoxetine hcl oral tablet 20 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
428
![Page 429: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/429.jpg)
FLUoxetine HClProducts Affected
• fluoxetine hcl oral capsule delayed release
QL Criteria 4 capsules Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
429
![Page 430: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/430.jpg)
FLUoxetine HClProducts Affected
• fluoxetine hcl oral tablet 10 mg
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
430
![Page 431: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/431.jpg)
FLUoxetine HClProducts Affected
• fluoxetine hcl oral capsule 20 mg
QL Criteria 4 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
431
![Page 432: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/432.jpg)
FLUoxetine HClProducts Affected
• fluoxetine hcl oral capsule 40 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
432
![Page 433: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/433.jpg)
FLUoxetine HClProducts Affected
• fluoxetine hcl oral capsule 10 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
433
![Page 434: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/434.jpg)
Fluvastatin SodiumProducts Affected
• fluvastatin sodium
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
434
![Page 435: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/435.jpg)
Fluvastatin Sodium ERProducts Affected
• fluvastatin sodium er
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
435
![Page 436: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/436.jpg)
FluvoxaMINE MaleateProducts Affected
• fluvoxamine maleate oral tablet 25 mg, 50 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
436
![Page 437: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/437.jpg)
FluvoxaMINE MaleateProducts Affected
• fluvoxamine maleate oral tablet 100 mg
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
437
![Page 438: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/438.jpg)
Focalin XRProducts Affected
• FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 35 MG, 25 MG
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 1 capsule Per 1 Day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
438
![Page 439: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/439.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
439
![Page 440: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/440.jpg)
Follistim AQProducts Affected
• FOLLISTIM AQ
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
440
![Page 441: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/441.jpg)
Fondaparinux SodiumProducts Affected
• fondaparinux sodium
QL Criteria 1 syringe Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
441
![Page 442: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/442.jpg)
FORA D10 2-in-1 MonitorProducts Affected
• FORA D10 2-IN-1 MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
442
![Page 443: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/443.jpg)
FORA D10 Blood Glucose TestProducts Affected
• FORA D10 BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
443
![Page 444: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/444.jpg)
FORA D15g 2-in-1 MonitorProducts Affected
• FORA D15G 2-IN-1 MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
444
![Page 445: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/445.jpg)
FORA D15g Blood Glucose TestProducts Affected
• FORA D15G BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
445
![Page 446: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/446.jpg)
FORA D20 2-in-1 MonitorProducts Affected
• FORA D20 2-IN-1 MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
446
![Page 447: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/447.jpg)
FORA D20 Blood Glucose TestProducts Affected
• FORA D20 BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
447
![Page 448: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/448.jpg)
FORA G20 Blood Glucose TestProducts Affected
• FORA G20 BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
448
![Page 449: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/449.jpg)
FORA G30a Blood Glucose SystemProducts Affected
• FORA G30A BLOOD GLUCOSE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
449
![Page 450: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/450.jpg)
FORA G30a Blood Glucose TestProducts Affected
• FORA G30A BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
450
![Page 451: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/451.jpg)
Fora GD20 Blood Glucose SystemProducts Affected
• FORA GD20 BLOOD GLUCOSE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
451
![Page 452: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/452.jpg)
Fora GD20 TestProducts Affected
• FORA GD20 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
452
![Page 453: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/453.jpg)
FORA V10 Blood Glucose SystemProducts Affected
• FORA V10 BLOOD GLUCOSE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
453
![Page 454: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/454.jpg)
FORA V10 Blood Glucose TestProducts Affected
• FORA V10 BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
454
![Page 455: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/455.jpg)
FORA V12 Blood Glucose SystemProducts Affected
• FORA V12 BLOOD GLUCOSE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
455
![Page 456: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/456.jpg)
FORA V12 Blood Glucose TestProducts Affected
• FORA V12 BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
456
![Page 457: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/457.jpg)
FORA V20 Blood Glucose SystemProducts Affected
• FORA V20 BLOOD GLUCOSE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
457
![Page 458: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/458.jpg)
FORA V20 Blood Glucose TestProducts Affected
• FORA V20 BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
458
![Page 459: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/459.jpg)
FORA V30a Blood Glucose SystemProducts Affected
• FORA V30A BLOOD GLUCOSE SYSTEM DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
459
![Page 460: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/460.jpg)
FORA V30a Blood Glucose TestProducts Affected
• FORA V30A BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
460
![Page 461: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/461.jpg)
ForaCare GD40 MonitorProducts Affected
• FORACARE GD40 MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
461
![Page 462: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/462.jpg)
ForaCare GD40 TestProducts Affected
• FORACARE GD40 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
462
![Page 463: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/463.jpg)
ForaCare premium V10Products Affected
• FORACARE PREMIUM V10
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
463
![Page 464: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/464.jpg)
ForaCare premium V10 TestProducts Affected
• FORACARE PREMIUM V10 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
464
![Page 465: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/465.jpg)
Foradil AerolizerProducts Affected
• FORADIL AEROLIZER
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
465
![Page 466: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/466.jpg)
ForteoProducts Affected
• FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
466
![Page 467: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/467.jpg)
FortestaProducts Affected
• FORTESTA
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 4 pumps Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
467
![Page 468: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/468.jpg)
ForticalProducts Affected
• FORTICAL
PA Criteria Criteria Details
Covered Uses Osteoporosis
Exclusion CriteriaNo failure of formulary bisphosphonates, use in combination with one or more bisphosphonates.
Required Medical Information
Documentation of a trial and failure of generic alendronate weekly (70mg weekly dose)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 bottle Per 1 month
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
468
![Page 469: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/469.jpg)
Fosamax Plus DProducts Affected
• FOSAMAX PLUS D
PA Criteria Criteria Details
Covered Uses Osteoporosis
Exclusion CriteriaNo failure of formulary bisphosphonates, use in combination with one or more bisphosphonates.
Required Medical Information
Documentation of a trial and failure of generic alendronate weekly (70mg weekly dose)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 4 tablets Per 1 month
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
469
![Page 470: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/470.jpg)
FragminProducts Affected
• FRAGMIN SUBCUTANEOUS* SOLUTION 5000 UNIT/0.2ML, 18000 UNT/0.72ML, 12500 UNIT/0.5ML, 2500 UNIT/0.2ML, 10000 UNIT/ML, 15000 UNIT/0.6ML
QL Criteria 1 syringe Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
470
![Page 471: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/471.jpg)
FragminProducts Affected
• FRAGMIN SUBCUTANEOUS* SOLUTION 95000 UNIT/3.8ML, 7500 UNIT/0.3ML, 25000 UNIT/ML
QL Criteria 1 syringe Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
471
![Page 472: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/472.jpg)
FreeStyle InsuLinx TestProducts Affected
• FREESTYLE INSULINX TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
472
![Page 473: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/473.jpg)
FreeStyle LiteProducts Affected
• FREESTYLE LITE
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
473
![Page 474: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/474.jpg)
FreeStyle Lite TestProducts Affected
• FREESTYLE LITE TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
474
![Page 475: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/475.jpg)
FreeStyle TestProducts Affected
• FREESTYLE TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
475
![Page 476: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/476.jpg)
Frovatriptan SuccinateProducts Affected
• frovatriptan succinate
ST Criteria Documented step through TWO of the following: SUMATRIPTAN, NARATRIPTAN, RIZATRIPTAN
QL Criteria 9 tablets Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
476
![Page 477: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/477.jpg)
GabapentinProducts Affected
• gabapentin oral tablet
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
477
![Page 478: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/478.jpg)
GabapentinProducts Affected
• gabapentin oral capsule
QL Criteria 6 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
478
![Page 479: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/479.jpg)
GammagardProducts Affected
• GAMMAGARD
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
479
![Page 480: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/480.jpg)
Gammagard S/D Less IgAProducts Affected
• GAMMAGARD S/D LESS IGA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
480
![Page 481: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/481.jpg)
GammakedProducts Affected
• GAMMAKED
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
481
![Page 482: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/482.jpg)
GammaplexProducts Affected
• GAMMAPLEX INTRAVENOUS* SOLUTION 5 GM/100ML, 10 GM/200ML, 2.5 GM/50ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
482
![Page 483: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/483.jpg)
Gamunex-CProducts Affected
• GAMUNEX-C
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
483
![Page 484: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/484.jpg)
Ganirelix AcetateProducts Affected
• ganirelix acetate
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
484
![Page 485: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/485.jpg)
GatifloxacinProducts Affected
• gatifloxacin ophthalmic
QL Criteria 1 bottle Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
485
![Page 486: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/486.jpg)
GattexProducts Affected
• GATTEX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Gattex.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 kit Per 1 month
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
486
![Page 487: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/487.jpg)
GaviLyte-CProducts Affected
• GAVILYTE-C
QL Criteria 4 liters Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
487
![Page 488: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/488.jpg)
GaviLyte-GProducts Affected
• GAVILYTE-G
QL Criteria 4 liters Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
488
![Page 489: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/489.jpg)
GE100 Blood Glucose TestProducts Affected
• ge100 blood glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
489
![Page 490: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/490.jpg)
GelniqueProducts Affected
• GELNIQUE TRANSDERMAL GEL 10 %
ST Criteria Documented step through OXYBUTYNIN or TROSPIUM AND VESICARE or MYRBETRIQ
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
490
![Page 491: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/491.jpg)
GelniqueProducts Affected
• GELNIQUE TRANSDERMAL GEL 3 (28) % (MG/ACT)
ST Criteria Documented step through OXYBUTYNIN or TROSPIUM AND VESICARE or MYRBETRIQ
QL Criteria 1 pump Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
491
![Page 492: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/492.jpg)
Generess FEProducts Affected
• GENERESS FE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
492
![Page 493: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/493.jpg)
GianviProducts Affected
• GIANVI
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
493
![Page 494: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/494.jpg)
GiazoProducts Affected
• GIAZO
ST Criteria Documented step through BALSALAZIDE
QL Criteria 6 tablets Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
494
![Page 495: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/495.jpg)
GildagiaProducts Affected
• GILDAGIA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
495
![Page 496: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/496.jpg)
Gildess 1.5/30Products Affected
• GILDESS 1.5/30
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
496
![Page 497: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/497.jpg)
Gildess 1/20Products Affected
• GILDESS 1/20
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
497
![Page 498: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/498.jpg)
Gildess FE 1.5/30Products Affected
• GILDESS FE 1.5/30
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
498
![Page 499: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/499.jpg)
Gildess FE 1/20Products Affected
• GILDESS FE 1/20
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
499
![Page 500: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/500.jpg)
GilenyaProducts Affected
• GILENYA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST CriteriaRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
500
![Page 501: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/501.jpg)
GilotrifProducts Affected
• GILOTRIF
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
501
![Page 502: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/502.jpg)
GlatopaProducts Affected
• GLATOPA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
502
![Page 503: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/503.jpg)
GlucaGen DiagnosticProducts Affected
• GLUCAGEN DIAGNOSTIC
QL Criteria 1 vial Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
503
![Page 504: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/504.jpg)
GlucaGen HypoKitProducts Affected
• GLUCAGEN HYPOKIT
QL Criteria 1 box Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
504
![Page 505: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/505.jpg)
Glucocard 01 Blood GlucoseProducts Affected
• GLUCOCARD 01 BLOOD GLUCOSE DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
505
![Page 506: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/506.jpg)
Glucocard 01 Sensor PlusProducts Affected
• GLUCOCARD 01 SENSOR PLUS
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
506
![Page 507: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/507.jpg)
Glucocard Expression TestProducts Affected
• GLUCOCARD EXPRESSION TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
507
![Page 508: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/508.jpg)
Glucocard Vital TestProducts Affected
• GLUCOCARD VITAL TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
508
![Page 509: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/509.jpg)
Glucocard X-SensorProducts Affected
• GLUCOCARD X-SENSOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
509
![Page 510: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/510.jpg)
GlucoCom Blood Glucose MonitorProducts Affected
• GLUCOCOM BLOOD GLUCOSE MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
510
![Page 511: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/511.jpg)
GlucoCom TestProducts Affected
• GLUCOCOM TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
511
![Page 512: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/512.jpg)
Gonal-fProducts Affected
• GONAL-F
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
512
![Page 513: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/513.jpg)
Gonal-f RFFProducts Affected
• GONAL-F RFF
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
513
![Page 514: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/514.jpg)
Gonal-f RFF PenProducts Affected
• GONAL-F RFF PEN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
514
![Page 515: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/515.jpg)
Gonal-f RFF RedijectProducts Affected
• GONAL-F RFF REDIJECT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
515
![Page 516: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/516.jpg)
GraliseProducts Affected
• GRALISE ORAL TABLET 300 MG
ST Criteria Documented step through GABAPENTIN
QL Criteria 1 tablet Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
516
![Page 517: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/517.jpg)
GraliseProducts Affected
• GRALISE ORAL TABLET 600 MG
ST Criteria Documented step through GABAPENTIN
QL Criteria 3 tablets Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
517
![Page 518: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/518.jpg)
Gralise StarterProducts Affected
• GRALISE STARTER
ST Criteria Documented step through GABAPENTIN
QL Criteria 1 starter pack Per 1 month
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
518
![Page 519: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/519.jpg)
Granisetron HClProducts Affected
• granisetron hcl oral
QL Criteria 10 tablets Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
519
![Page 520: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/520.jpg)
GuanFACINE HCl ERProducts Affected
• guanfacine hcl er
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
520
![Page 521: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/521.jpg)
Guardian REAL-Time System PedProducts Affected
• GUARDIAN REAL-TIME SYSTEM PED
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
521
![Page 522: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/522.jpg)
HalavenProducts Affected
• HALAVEN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Halaven.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 23, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
522
![Page 523: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/523.jpg)
HarvoniProducts Affected
• HARVONI
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 EA Per 1 Day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
523
![Page 524: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/524.jpg)
Helixate FSProducts Affected
• HELIXATE FS
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
524
![Page 525: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/525.jpg)
Hemofil MProducts Affected
• HEMOFIL M INTRAVENOUS* SOLUTION RECONSTITUTED 220-400 UNIT, 250 UNIT, 1000 UNIT, 1700 UNIT, 500 UNIT, 1501-2000 UNIT, 801-1500 UNIT, 401-800 UNIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
525
![Page 526: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/526.jpg)
HepseraProducts Affected
• HEPSERA
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
526
![Page 527: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/527.jpg)
HizentraProducts Affected
• HIZENTRA SUBCUTANEOUS* SOLUTION 10 GM/50ML, 1 GM/5ML, 4 GM/20ML, 2 GM/10ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
527
![Page 528: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/528.jpg)
HM NicotineProducts Affected
• hm nicotine transdermal patch 24 hr 7 mg/24hr
QL Criteria 1 patch Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
528
![Page 529: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/529.jpg)
HorizantProducts Affected
• HORIZANT ORAL TABLET EXTENDEDRELEASE* 600 MG
ST CriteriaFOR POST-HERPTIC NEURALGIA: Documented step through gabapentin. FOR RESTLESS LESG SYNDROME: Documented step through gabapentin or ropinirole.
QL Criteria 2 tablets Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
529
![Page 530: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/530.jpg)
HorizantProducts Affected
• HORIZANT ORAL TABLET EXTENDEDRELEASE* 300 MG
ST CriteriaFOR POST-HERPTIC NEURALGIA: Documented step through gabapentin. FOR RESTLESS LESG SYNDROME: Documented step through gabapentin or ropinirole.
QL Criteria 1 tablet Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
530
![Page 531: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/531.jpg)
Humate-PProducts Affected
• HUMATE-P INTRAVENOUS* SOLUTION RECONSTITUTED 500-1200 UNIT, 1000-2400 UNIT, 250-600 UNIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
531
![Page 532: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/532.jpg)
HumiraProducts Affected
• HUMIRA SUBCUTANEOUS* 10 MG/0.2ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
532
![Page 533: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/533.jpg)
HumiraProducts Affected
• HUMIRA SUBCUTANEOUS* 20 MG/0.4ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 injections Per 28 kit (2 pens)s
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
533
![Page 534: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/534.jpg)
HumiraProducts Affected
• HUMIRA SUBCUTANEOUS* 40 MG/0.8ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 6 injections Per 28 kit (2 pens)s
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
534
![Page 535: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/535.jpg)
Humira Pediatric Crohns StartProducts Affected
• HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 injections Per 21 months
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
535
![Page 536: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/536.jpg)
Humira PenProducts Affected
• HUMIRA PEN SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 6 injections Per 28 kit (2 pens)s
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
536
![Page 537: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/537.jpg)
Humira Pen-Crohns StarterProducts Affected
• HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 injections Per 21 months
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
537
![Page 538: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/538.jpg)
Humira Pen-Psoriasis StarterProducts Affected
• HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 6 injections Per 28 months
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
538
![Page 539: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/539.jpg)
HycamtinProducts Affected
• HYCAMTIN ORAL
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
539
![Page 540: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/540.jpg)
Hydrocod Polst-CPM Polst ERProducts Affected
• hydrocod polst-cpm polst er oral liquid extendedrelease*
QL Criteria 120 milliliters Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
540
![Page 541: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/541.jpg)
HYDROmorphone HCl ERProducts Affected
• hydromorphone hcl er
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
541
![Page 542: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/542.jpg)
Ibandronate SodiumProducts Affected
• ibandronate sodium oral
PA Criteria Criteria Details
Covered Uses Osteoporosis
Exclusion CriteriaNo failure of formulary bisphosphonates, use in combination with one or more bisphosphonates.
Required Medical Information
Documentation of a trial and failure of generic alendronate weekly (70mg weekly dose)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 tablet Per 1 month
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
542
![Page 543: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/543.jpg)
IclusigProducts Affected
• ICLUSIG ORAL TABLET 45 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
543
![Page 544: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/544.jpg)
IclusigProducts Affected
• ICLUSIG ORAL TABLET 15 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
544
![Page 545: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/545.jpg)
IlarisProducts Affected
• ILARIS
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/immunomodulators_CAP.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
545
![Page 546: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/546.jpg)
Imatinib MesylateProducts Affected
• imatinib mesylate oral tablet 100 mg
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 3 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
546
![Page 547: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/547.jpg)
Imatinib MesylateProducts Affected
• imatinib mesylate oral tablet 400 mg
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
547
![Page 548: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/548.jpg)
ImiquimodProducts Affected
• imiquimod external
QL Criteria 48 packets Per 112 dayss
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
548
![Page 549: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/549.jpg)
ImplanonProducts Affected
• IMPLANON
QL Criteria 1 implant Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
549
![Page 550: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/550.jpg)
IncrelexProducts Affected
• INCRELEX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/Increlex.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
550
![Page 551: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/551.jpg)
Infinity Blood Glucose TestProducts Affected
• INFINITY BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
551
![Page 552: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/552.jpg)
InlytaProducts Affected
• INLYTA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
552
![Page 553: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/553.jpg)
IntelenceProducts Affected
• INTELENCE ORAL TABLET 100 MG, 25 MG
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
553
![Page 554: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/554.jpg)
IntelenceProducts Affected
• INTELENCE ORAL TABLET 200 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
554
![Page 555: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/555.jpg)
Intron AProducts Affected
• INTRON A
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
555
![Page 556: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/556.jpg)
IntrovaleProducts Affected
• INTROVALE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
556
![Page 557: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/557.jpg)
InvokanaProducts Affected
• INVOKANA
ST Criteria Documented step through METFORMIN 1500MG/day
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
557
![Page 558: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/558.jpg)
Ipratropium BromideProducts Affected
• ipratropium bromide nasal
QL Criteria 1 bottle Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
558
![Page 559: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/559.jpg)
IrbesartanProducts Affected
• irbesartan
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
559
![Page 560: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/560.jpg)
Irbesartan-HydrochlorothiazideProducts Affected
• irbesartan-hydrochlorothiazide
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
560
![Page 561: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/561.jpg)
IsentressProducts Affected
• ISENTRESS ORAL TABLET
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
561
![Page 562: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/562.jpg)
IsentressProducts Affected
• ISENTRESS ORAL TABLET CHEWABLE
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
562
![Page 563: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/563.jpg)
IstodaxProducts Affected
• ISTODAX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Istodax.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 23, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
563
![Page 564: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/564.jpg)
ItraconazoleProducts Affected
• itraconazole oral
PA Criteria Criteria Details
Covered UsesOnychomycosis, invasive fungal infection, uther fungal infection, superficial mycoses
Exclusion Criteria
Cosmetic use, patients with evidence of ventricular dysfunction such as CHF or a history of CHF. Coadministration with certain drugs metabolized by the cytochrome P-450 3A4 isoenzyme system (CYP3A4), cisapride, oral midazolam, pimozide, quinidine, dofetilide, triazolam, HMG-CoA reductase inhibitors metabolized by CYP3A4, such as lovastatin and simvastatin, and ergot alkaloids metabolized by CYP3A4, such as dihydroergotamine, ergotamine, ergonovine, and methylergonovine.
Required Medical Information
Itraconazole Capsules are covered for members who meet the following criteria: (1) Invasive fungal infections in patients who are immunocompromised, such as histoplamosis, aspergillosis, and blastomycosis, (2) Treatment of tinea barbae, tinea capitis, tinea favosa with previous treatment with terbinafine, (3) Treatment of tinea corporis, tinea cruris, tinea faciei, tinea manuum, tinea pedis with previous treatment with a topical antifungal and terbinafine, (4) Treatment of tinea versicolor with previous treatment with selenium sulfide and a topcial antifungal, (5) a diagnosis of majocchi granuloma, (6) Onychomycosis in diabetic patients or patients with peripheral vascular disease and either a positive onychomycosis susceptible pathogen culture or a positive PAS stain performed by a laboratory and documented trial/failure of terbinafine (generic Lamisil), or (7) Onychomycosis with documented disabling pain or impairment and a positive onychomycosis susceptible pathogen culture and documented step through terbinafine.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Nail: 12 wk(toe),5 wk (finger) per year,Invasive: 1-3 mo based on severity, Other Dx: 1-6 wk
Other Criteria
QL Criteria 4 capsules Per 1 Day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
564
![Page 565: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/565.jpg)
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
565
![Page 566: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/566.jpg)
JakafiProducts Affected
• JAKAFI
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
566
![Page 567: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/567.jpg)
JanumetProducts Affected
• JANUMET
ST Criteria Documented step through METFORMIN ER (at least 1500mg/day) AND TRADJENTA/JENTADUETO or ONGLYZA/KOMBIGLYZE XR
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
567
![Page 568: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/568.jpg)
Janumet XRProducts Affected
• JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 50-1000 MG
ST Criteria Documented step through METFORMIN ER (at least 1500mg/day) AND TRADJENTA/JENTADUETO or ONGLYZA/KOMBIGLYZE XR
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
568
![Page 569: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/569.jpg)
Janumet XRProducts Affected
• JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-500 MG
ST Criteria Documented step through METFORMIN ER (at least 1500mg/day) AND TRADJENTA/JENTADUETO or ONGLYZA/KOMBIGLYZE XR
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
569
![Page 570: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/570.jpg)
JanuviaProducts Affected
• JANUVIA
ST Criteria Documented step through METFORMIN ER (at least 1500mg/day) AND TRADJENTA/JENTADUETO or ONGLYZA/KOMBIGLYZE XR
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
570
![Page 571: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/571.jpg)
JentaduetoProducts Affected
• JENTADUETO
ST Criteria Documented step through METFORMIN 1500MG/day
QL Criteria 2 tablets Per 1 day
Notes/References Annual Review: 05/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
571
![Page 572: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/572.jpg)
Jentadueto XRProducts Affected
• JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG
QL Criteria 2 tablets Per 1 Day
Notes/References Annual Review: 05/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
572
![Page 573: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/573.jpg)
Jentadueto XRProducts Affected
• JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG
QL Criteria 1 tablet Per 1 Day
Notes/References Annual Review: 05/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
573
![Page 574: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/574.jpg)
Jevantique LoProducts Affected
• jevantique lo
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
574
![Page 575: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/575.jpg)
JinteliProducts Affected
• JINTELI
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
575
![Page 576: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/576.jpg)
JolessaProducts Affected
• JOLESSA
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
576
![Page 577: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/577.jpg)
JolivetteProducts Affected
• JOLIVETTE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
577
![Page 578: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/578.jpg)
Junel 1.5/30Products Affected
• JUNEL 1.5/30
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
578
![Page 579: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/579.jpg)
Junel 1/20Products Affected
• JUNEL 1/20
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
579
![Page 580: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/580.jpg)
Junel FE 1.5/30Products Affected
• JUNEL FE 1.5/30
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
580
![Page 581: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/581.jpg)
Junel FE 1/20Products Affected
• JUNEL FE 1/20
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
581
![Page 582: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/582.jpg)
JuxtapidProducts Affected
• JUXTAPID ORAL CAPSULE 60 MG, 40 MG, 30 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/Antilipidemic Agents_HOFH.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 EA Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
582
![Page 583: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/583.jpg)
JuxtapidProducts Affected
• JUXTAPID ORAL CAPSULE 20 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/Antilipidemic Agents_HOFH.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 3 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
583
![Page 584: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/584.jpg)
JuxtapidProducts Affected
• JUXTAPID ORAL CAPSULE 5 MG, 10 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/Antilipidemic Agents_HOFH.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
584
![Page 585: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/585.jpg)
KadianProducts Affected
• KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 40 MG, 130 MG, 70 MG
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
Notes/References
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
585
![Page 586: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/586.jpg)
KalydecoProducts Affected
• KALYDECO ORAL TABLET
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/cystic_fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: December 21, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
586
![Page 587: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/587.jpg)
KarivaProducts Affected
• KARIVA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
587
![Page 588: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/588.jpg)
Kelnor 1/35Products Affected
• KELNOR 1/35
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
588
![Page 589: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/589.jpg)
KepivanceProducts Affected
• KEPIVANCE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
589
![Page 590: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/590.jpg)
KetoconazoleProducts Affected
• ketoconazole oral
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
590
![Page 591: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/591.jpg)
Ketorolac TromethamineProducts Affected
• ketorolac tromethamine ophthalmic
QL Criteria 1 vial Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
591
![Page 592: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/592.jpg)
Ketorolac TromethamineProducts Affected
• ketorolac tromethamine oral
QL Criteria 20 tablets Per 28 dayss
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
592
![Page 593: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/593.jpg)
KineretProducts Affected
• KINERET SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Kineret.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Kineret.html
QL Criteria 1 syringe Per 1 day
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
593
![Page 594: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/594.jpg)
Koate-DVIProducts Affected
• KOATE-DVI
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
594
![Page 595: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/595.jpg)
Kogenate FSProducts Affected
• KOGENATE FS
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
595
![Page 596: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/596.jpg)
Kogenate FS Bio-SetProducts Affected
• KOGENATE FS BIO-SET
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
596
![Page 597: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/597.jpg)
Kombiglyze XRProducts Affected
• KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG
ST Criteria Documented step through METFORMIN 1500MG/day
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
597
![Page 598: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/598.jpg)
Kombiglyze XRProducts Affected
• KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG, 5-500 MG
ST Criteria Documented step through METFORMIN 1500MG/day
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
598
![Page 599: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/599.jpg)
KorlymProducts Affected
• KORLYM
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/antidiabetic%20agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: February 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
599
![Page 600: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/600.jpg)
KovaltryProducts Affected
• KOVALTRY
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
600
![Page 601: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/601.jpg)
Kroger Blood Glucose TestProducts Affected
• kroger blood glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
601
![Page 602: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/602.jpg)
Kroger Premium Glucose TestProducts Affected
• kroger premium glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
602
![Page 603: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/603.jpg)
Kroger TestProducts Affected
• kroger test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
603
![Page 604: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/604.jpg)
KurveloProducts Affected
• KURVELO
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
604
![Page 605: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/605.jpg)
KuvanProducts Affected
• KUVAN ORAL PACKET 500 MG • KUVAN ORAL TABLET SOLUBLE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 31, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
605
![Page 606: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/606.jpg)
LamISILProducts Affected
• LAMISIL ORAL PACKET 125 MG
QL Criteria 2 packs Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
606
![Page 607: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/607.jpg)
LamISILProducts Affected
• LAMISIL ORAL PACKET 187.5 MG
QL Criteria 1 patch Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
607
![Page 608: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/608.jpg)
LamoTRIgineProducts Affected
• lamotrigine oral tablet dispersible 100 mg, 200 mg
PA Criteria Criteria Details
Covered UsesDiagnosis of epilepsy or Bipolar I disorder (Bipolar I disorder ONLY in the case of Lamictal ODT)
Exclusion Criteria
Required Medical Information
The member has a documented diagnosis of epilepsy or Bipolar I disorder (Bipolar I disorder ONLY in the case of Lamictal ODT) and either documentation of unsatisfactory effects with, intolerability to, or inability to take immediate-release lamotrigine, or in the case of Lamotrigine ER, the member is new to the health plan and has been established on therapy for longer than four weeks with Lamotrigine ER.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years for Lamotrigine ER. 1 year for Lamictal ODT.
Other Criteria
QL Criteria 2 TABS Per 1 DAYS
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
608
![Page 609: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/609.jpg)
LamoTRIgineProducts Affected
• lamotrigine oral tablet dispersible 50 mg
PA Criteria Criteria Details
Covered UsesDiagnosis of epilepsy or Bipolar I disorder (Bipolar I disorder ONLY in the case of Lamictal ODT)
Exclusion Criteria
Required Medical Information
The member has a documented diagnosis of epilepsy or Bipolar I disorder (Bipolar I disorder ONLY in the case of Lamictal ODT) and either documentation of unsatisfactory effects with, intolerability to, or inability to take immediate-release lamotrigine, or in the case of Lamotrigine ER, the member is new to the health plan and has been established on therapy for longer than four weeks with Lamotrigine ER.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years for Lamotrigine ER. 1 year for Lamictal ODT.
Other Criteria
QL Criteria 3 TABS Per 1 DAYS
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
609
![Page 610: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/610.jpg)
LamoTRIgineProducts Affected
• lamotrigine oral tablet dispersible 25 mg
PA Criteria Criteria Details
Covered UsesDiagnosis of epilepsy or Bipolar I disorder (Bipolar I disorder ONLY in the case of Lamictal ODT)
Exclusion Criteria
Required Medical Information
The member has a documented diagnosis of epilepsy or Bipolar I disorder (Bipolar I disorder ONLY in the case of Lamictal ODT) and either documentation of unsatisfactory effects with, intolerability to, or inability to take immediate-release lamotrigine, or in the case of Lamotrigine ER, the member is new to the health plan and has been established on therapy for longer than four weeks with Lamotrigine ER.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years for Lamotrigine ER. 1 year for Lamictal ODT.
Other Criteria
QL Criteria 6 TABS Per 1 DAYS
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
610
![Page 611: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/611.jpg)
LamoTRIgine ERProducts Affected
• lamotrigine er oral tablet extended release 24 hr* 200 mg
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
611
![Page 612: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/612.jpg)
LamoTRIgine ERProducts Affected
• lamotrigine er oral tablet extended release 24 hr* 250 mg, 300 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
612
![Page 613: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/613.jpg)
LamoTRIgine ERProducts Affected
• lamotrigine er oral tablet extended release 24 hr* 50 mg
QL Criteria 1 TB24 Per 1 DAYS
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
613
![Page 614: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/614.jpg)
LamoTRIgine ERProducts Affected
• lamotrigine er oral tablet extended release 24 hr* 100 mg, 25 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
614
![Page 615: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/615.jpg)
LansoprazoleProducts Affected
• lansoprazole oral capsule delayed release
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
615
![Page 616: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/616.jpg)
LantusProducts Affected
• LANTUS
ST Criteria Documented step through LEVEMIR VIAL
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
616
![Page 617: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/617.jpg)
Lantus SoloStarProducts Affected
• LANTUS SOLOSTAR SUBCUTANEOUS*
ST Criteria Documented step through LEVEMIR VIAL
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
617
![Page 618: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/618.jpg)
Larin Fe 1.5/30Products Affected
• LARIN FE 1.5/30
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
618
![Page 619: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/619.jpg)
LastacaftProducts Affected
• LASTACAFT
QL Criteria 1 bottle Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
619
![Page 620: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/620.jpg)
LatanoprostProducts Affected
• latanoprost ophthalmic
QL Criteria 1 bottle Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
620
![Page 621: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/621.jpg)
LatudaProducts Affected
• LATUDA ORAL TABLET 20 MG, 120 MG, 60 MG, 40 MG
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
621
![Page 622: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/622.jpg)
LatudaProducts Affected
• LATUDA ORAL TABLET 80 MG
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
622
![Page 623: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/623.jpg)
LeenaProducts Affected
• LEENA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
623
![Page 624: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/624.jpg)
LeflunomideProducts Affected
• leflunomide oral
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
624
![Page 625: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/625.jpg)
LemtradaProducts Affected
• LEMTRADA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
QL Criteria 6 ML Per 365 Days
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
625
![Page 626: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/626.jpg)
LessinaProducts Affected
• LESSINA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
626
![Page 627: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/627.jpg)
LetairisProducts Affected
• LETAIRIS
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
627
![Page 628: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/628.jpg)
LeukineProducts Affected
• LEUKINE INTRAVENOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/GCSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: November 08, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
628
![Page 629: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/629.jpg)
Leuprolide AcetateProducts Affected
• leuprolide acetate injection
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
629
![Page 630: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/630.jpg)
Levalbuterol Tartrate HFAProducts Affected
• levalbuterol tartrate hfa
ST Criteria Documented step through VENTOLIN HFA
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
630
![Page 631: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/631.jpg)
LevETIRAcetam ERProducts Affected
• levetiracetam er oral tablet extended release 24 hr* 500 mg
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
631
![Page 632: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/632.jpg)
LevETIRAcetam ERProducts Affected
• levetiracetam er oral tablet extended release 24 hr* 750 mg
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
632
![Page 633: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/633.jpg)
Levocetirizine DihydrochlorideProducts Affected
• levocetirizine dihydrochloride oral tablet
ST Criteria Documented step through TWO of the following: CLARITIN OTC, ZYRTEC OTC, ALLEGRA OTC
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
633
![Page 634: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/634.jpg)
Levocetirizine DihydrochlorideProducts Affected
• levocetirizine dihydrochloride oral solution
ST Criteria Documented step through TWO of the following: CLARITIN OTC, ZYRTEC OTC, ALLEGRA OTC
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
634
![Page 635: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/635.jpg)
LevonestProducts Affected
• LEVONEST
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
635
![Page 636: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/636.jpg)
Levonorgest-Eth Estrad 91-DayProducts Affected
• levonorgest-eth estrad 91-day oral tablet0.15-0.03 mg, 0.1-0.02 & 0.01 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
636
![Page 637: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/637.jpg)
Levonorgestrel-Ethinyl EstradProducts Affected
• levonorgestrel-ethinyl estrad oral tablet0.15-30 mg-mcg
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
637
![Page 638: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/638.jpg)
Levora 0.15/30 (28)Products Affected
• LEVORA 0.15/30 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
638
![Page 639: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/639.jpg)
LialdaProducts Affected
• LIALDA
ST Criteria Documented failure, contraindication or intolerance to Apriso
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
639
![Page 640: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/640.jpg)
Liberty Blood Glucose MeterProducts Affected
• liberty blood glucose meter
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
640
![Page 641: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/641.jpg)
Liberty Blood Glucose MonitorProducts Affected
• liberty blood glucose monitor
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
641
![Page 642: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/642.jpg)
Liberty Next Generation TestProducts Affected
• LIBERTY NEXT GENERATION TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
642
![Page 643: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/643.jpg)
Liberty Nxt Generation MonitorProducts Affected
• LIBERTY NXT GENERATION MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
643
![Page 644: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/644.jpg)
Liberty TestProducts Affected
• liberty test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
644
![Page 645: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/645.jpg)
LidocaineProducts Affected
• lidocaine external ointment
PA Criteria Criteria Details
Covered Uses
***AUTHORIZATION IS NOT REQUIRED FOR LESS THAN 50 GRAMS OF LIDOCAINE EVERY 30 DAYS*** For quantities over 50 grams every 30 days, there must be a documented temporary need for anesthesia for any of the following: Accessible mucous membranes of the oropharynx, skin and mucous membranes or stomatitis, or pain associated with a minor burns, including sunburn, abrasions of the skin, and insect bites.
Exclusion Criteria
Documentation of any of the following: Planned area of application includes non-intact skin, sensitivity to amide-type local anesthetics or any other component of the product, planned use on large surface area of the body as this can lead to increased toxicity, planned area of application includes severely traumatized skin (e.g.,mucosal or skin abrasion, eczema, burns), the medication is being used in conjunction with a cosmetic procedure (i.e. hair removal), of if the product will be compounded with other products that would alter the total dose/dosage form being administered
Required Medical Information
A documented need for temporary anesthesia for any of the following: Accessible mucous membranes of the oropharynx, skin and mucous membranes or stomatitis, or pain associated with a minor burns, including sunburn, abrasions of the skin, and insect bites.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 months
2016 Innovation Health Leap Drug GuideLast update 12/2016
645
![Page 646: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/646.jpg)
PA Criteria Criteria Details
Other Criteria
*Topical lidocaine ointment is used for temporary anesthesia. Prescription renewals for longer than 3 months require clinical documentation of medical necessity. Due to Safety Concerns higher quantities and prolonged use are not recommended. Renewal Duration: 3 months *Approval can made up to an additional 50gms per 30 days. Higher additional quantities are not approvable *FOR ADULTS: A single application should not exceed 5 g of Lidocaine Ointment 5%, containing 250 mg of lidocaine base (equivalent chemically to approximately 300 mg of lidocaine hydrochloride). This is roughly equivalent to squeezing a six (6) inch length of ointment from the tube. In a 70 kg adult this dose equals 3.6 mg/kg (1.6 mg/lb) lidocaine base. No more than one-half tube, approximately 17-20 g of ointment or 850-1000 mg lidocaine base, should be administered in any one day. FOR CHILDREN: For children less than ten years who have a normal lean body mass and a normal lean body development, the maximum dose may be determined by the application of one of the standard pediatric drug formulas (e.g., Clark's rule). For example a child of five years weighing 50 lbs., the dose of lidocaine should not exceed 75-100 mg when calculated according to Clark's rule. In any case, the maximum amount of lidocaine administered should not exceed 4.5 mg/kg (2.0 mg/lb) of body weight ***Lidocaine toxicity resulting from transcutaneous absorption is theoretically possible. Signs and symptoms of systemic lidocaine toxicity include CNS excitation and/or depression, nervousness, confusion, dizziness, tinnitus, blurred or double vision, vomiting, twitching, tremors, seizures, unconsciousness, respiratory depression, bradycardia, hypotension, and cardiopulmonary arrest. If there is suspicion of lidocaine-related systemic toxicity, check lidocaine blood concentrations
QL Criteria 50 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: October 03, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
646
![Page 647: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/647.jpg)
LidocaineProducts Affected
• lidocaine external patch 5 %
PA Criteria Criteria Details
Covered Uses pain associated with post-herpetic neuralgia
Exclusion Criteria
Required Medical Information
Documented diagnosis of pain associated with post-herpetic neuralgia
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
Notes/References
Revision DatePrior Authorization: October 21, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
647
![Page 648: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/648.jpg)
Lidocaine-PrilocaineProducts Affected
• lidocaine-prilocaine external cream
PA Criteria Criteria Details
Covered Uses
***AUTHORIZATION IS NOT REQUIRED FOR LESS THAN 50 GRAMS OF LIDOCAINE EVERY 30 DAYS*** For quantities over 50 grams every 30 days, there must be a documented temporary need for topical anesthetic in either of the following situations: Normal, intact skin for local analgesia, or Genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia
Exclusion Criteria
Documentation of any of the following: Planned area of application includes non-intact skin, Sensitivity to amide-type local anesthetics or any other component of the product, Planned use on large surface area of the body or for a period of time over 3 hours as this can lead to increased toxicity, the medication is being used in conjunction with a cosmetic procedure (i.e. hair removal), Use in situations where the drug may migrate into the middle ear, beyond the tympanic membrane, History of methemoglobinemia, or if the product will be compounded with other products that would alter the total dose/dosage form being administered
Required Medical Information
A documented need for topical anesthetic in either of the following situations: Normal, intact skin for local analgesia, or Genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 months
Other Criteria
*Topical lidocaine/prilocaine cream is used for temporary anesthesia. Prescription renewals for longer than 3 months require clinical documentation of medical necessity.Due to Safety Concerns higher quantities and prolonged use are not recommended. Renewal Duration: 3 months *Up to an additional 30 grams per 30 days. Higher additional quantities are not approvable.
QL Criteria 30 grams Per 30 Days
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
648
![Page 649: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/649.jpg)
Revision DatePrior Authorization: October 03, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
649
![Page 650: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/650.jpg)
LindaneProducts Affected
• lindane external lotion
QL Criteria 1 bottle Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
650
![Page 651: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/651.jpg)
LinezolidProducts Affected
• linezolid oral suspension reconstituted
QL Criteria 150 ml Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
651
![Page 652: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/652.jpg)
LinezolidProducts Affected
• linezolid oral tablet
QL Criteria 28 tablets Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
652
![Page 653: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/653.jpg)
LinzessProducts Affected
• LINZESS
ST Criteria Documented step through LACTULOSE OR POLYETHYLENE GLYCOL
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
653
![Page 654: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/654.jpg)
LivaloProducts Affected
• LIVALO
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
654
![Page 655: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/655.jpg)
Lo Loestrin FeProducts Affected
• LO LOESTRIN FE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
655
![Page 656: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/656.jpg)
Loestrin Fe 1.5/30Products Affected
• LOESTRIN FE 1.5/30
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
656
![Page 657: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/657.jpg)
Loestrin Fe 1/20Products Affected
• LOESTRIN FE 1/20
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
657
![Page 658: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/658.jpg)
Lomedia 24 FEProducts Affected
• LOMEDIA 24 FE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
658
![Page 659: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/659.jpg)
LorynaProducts Affected
• LORYNA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
659
![Page 660: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/660.jpg)
LoSeasoniqueProducts Affected
• LOSEASONIQUE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
660
![Page 661: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/661.jpg)
LovastatinProducts Affected
• lovastatin
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
661
![Page 662: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/662.jpg)
Low-OgestrelProducts Affected
• LOW-OGESTREL
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
662
![Page 663: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/663.jpg)
LumiganProducts Affected
• LUMIGAN OPHTHALMIC SOLUTION 0.01 %
PA Criteria Criteria Details
Covered Uses Glaucoma
Exclusion Criteria
Required Medical Information
Documented step through latanoprost.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 bottle Per 1 month
Notes/References Annual Review: 03/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
663
![Page 664: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/664.jpg)
LumizymeProducts Affected
• LUMIZYME
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
664
![Page 665: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/665.jpg)
Lupaneta PackProducts Affected
• LUPANETA PACK
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
665
![Page 666: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/666.jpg)
Lupron DepotProducts Affected
• LUPRON DEPOT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
666
![Page 667: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/667.jpg)
Lupron Depot-PedProducts Affected
• LUPRON DEPOT-PED
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
667
![Page 668: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/668.jpg)
LuteraProducts Affected
• LUTERA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
668
![Page 669: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/669.jpg)
LyricaProducts Affected
• LYRICA
PA Criteria Criteria Details
Covered UsesEpilepsy, Diabetic peripheral neuropathy, Post-herpetic neuropathy, Fibromyalgia, Neuropathic pain associated with spinal cord injury
Exclusion Criteria
Required Medical Information
Epilepsy as adjunct therapy, or diabetic peripheral neuropathy with documented failure of gabapentin, or post-herpetic neuropathy with documented failure of gabapentin, or documentation of the diagnosis of Fibromyalgia and documented failure of non-pharmacologic therapies (cognitive behavioral therapies, exercise etc.) and three (3) of the following drugs/drug classes: tricyclic antidepressant (eg: amitriptyline), muscle relaxant (eg: cyclobenzaprine), SSRI, SNRI, gabapentin, tramadol, or members with documented neuropathic pain associated with spinal cord injury with documented failure of three (3) of the following drugs/drug classes: tricyclic antidepressant (eg: amitriptyline), one muscle relaxant (eg: baclofen), SNRI, gabapentin, tramadol
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
669
![Page 670: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/670.jpg)
LyzaProducts Affected
• LYZA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
670
![Page 671: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/671.jpg)
MalathionProducts Affected
• malathion external
QL Criteria 1 bottle Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
671
![Page 672: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/672.jpg)
MarlissaProducts Affected
• marlissa
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
672
![Page 673: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/673.jpg)
Matzim LAProducts Affected
• MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 300 MG, 420 MG, 360 MG
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
673
![Page 674: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/674.jpg)
Matzim LAProducts Affected
• MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 240 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
674
![Page 675: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/675.jpg)
Maxima Blood Glucose TestProducts Affected
• MAXIMA BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
675
![Page 676: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/676.jpg)
MedroxyPROGESTERone AcetateProducts Affected
• medroxyprogesterone acetate intramuscular* suspension
QL Criteria 1 syringe Per 90 dayss
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
676
![Page 677: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/677.jpg)
Meijer Blood Glucose TestProducts Affected
• meijer blood glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
677
![Page 678: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/678.jpg)
Meijer Premium Glucose TestProducts Affected
• meijer premium glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
678
![Page 679: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/679.jpg)
Memantine HClProducts Affected
• memantine hcl oral tablet 10 mg, 5 mg
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
679
![Page 680: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/680.jpg)
Memantine HClProducts Affected
• memantine hcl oral tablet 5 (28)-10 (21) mg
QL Criteria 1 pack Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
680
![Page 681: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/681.jpg)
MenopurProducts Affected
• MENOPUR
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
681
![Page 682: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/682.jpg)
MenostarProducts Affected
• MENOSTAR
QL Criteria 1 box (4 patches) Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
682
![Page 683: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/683.jpg)
MesalamineProducts Affected
• mesalamine oral
QL Criteria 6 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
683
![Page 684: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/684.jpg)
Metadate ERProducts Affected
• METADATE ER ORAL TABLET EXTENDEDRELEASE* 20 MG
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 3 tablets Per 1 day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
684
![Page 685: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/685.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
685
![Page 686: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/686.jpg)
MetaxaloneProducts Affected
• metaxalone oral tablet 400 mg
QL Criteria 56 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
686
![Page 687: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/687.jpg)
MetFORMIN HCl ER (MOD)Products Affected
• metformin hcl er (mod)
ST Criteria Documented trial and failure of both generic Glucophage and generic Glucophage XR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
687
![Page 688: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/688.jpg)
Methamphetamine HClProducts Affected
• methamphetamine hcl
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
688
![Page 689: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/689.jpg)
MethylinProducts Affected
• METHYLIN ORAL TABLET CHEWABLE
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
689
![Page 690: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/690.jpg)
Methylphenidate HClProducts Affected
• methylphenidate hcl oral solution 10 mg/5ml
QL Criteria 30 milliliters Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
690
![Page 691: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/691.jpg)
Methylphenidate HClProducts Affected
• methylphenidate hcl oral solution 5 mg/5ml
QL Criteria 60 milliliters Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
691
![Page 692: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/692.jpg)
Methylphenidate HClProducts Affected
• methylphenidate hcl oral tablet
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
692
![Page 693: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/693.jpg)
Methylphenidate HCl ERProducts Affected
• methylphenidate hcl er oral tablet extended release 24 hr* 27 mg, 18 mg, 54 mg
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
693
![Page 694: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/694.jpg)
Methylphenidate HCl ERProducts Affected
• methylphenidate hcl er oral tablet extendedrelease* 27 mg, 18 mg, 54 mg
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
694
![Page 695: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/695.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
695
![Page 696: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/696.jpg)
Methylphenidate HCl ERProducts Affected
• methylphenidate hcl er oral tablet extendedrelease* 10 mg, 20 mg
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 3 tablets Per 1 day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
696
![Page 697: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/697.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
697
![Page 698: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/698.jpg)
Methylphenidate HCl ERProducts Affected
• methylphenidate hcl er oral tablet extendedrelease* 36 mg
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 4 tablets Per 1 Day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
698
![Page 699: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/699.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
699
![Page 700: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/700.jpg)
Methylphenidate HCl ERProducts Affected
• methylphenidate hcl er oral tablet extended release 24 hr* 36 mg
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
700
![Page 701: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/701.jpg)
Methylphenidate HCl ER (CD)Products Affected
• methylphenidate hcl er (cd)
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 1 capsule Per 1 day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
701
![Page 702: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/702.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
702
![Page 703: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/703.jpg)
Methylphenidate HCl ER (LA)Products Affected
• methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 1 capsule Per 1 day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
703
![Page 704: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/704.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
704
![Page 705: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/705.jpg)
Methylphenidate HCl ER (LA)Products Affected
• methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 2 capsules Per 1 day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
705
![Page 706: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/706.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
706
![Page 707: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/707.jpg)
Metoprolol Succinate ERProducts Affected
• metoprolol succinate er oral tablet extended release 24 hr* 200 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
707
![Page 708: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/708.jpg)
Metoprolol Succinate ERProducts Affected
• metoprolol succinate er oral tablet extended release 24 hr* 25 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
708
![Page 709: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/709.jpg)
Metoprolol Succinate ERProducts Affected
• metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 50 mg
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
709
![Page 710: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/710.jpg)
MiacalcinProducts Affected
• MIACALCIN INJECTION
PA Criteria Criteria Details
Covered Uses Osteoporosis
Exclusion CriteriaNo failure of formulary bisphosphonates, use in combination with one or more bisphosphonates.
Required Medical Information
Documentation of a trial and failure of generic alendronate weekly (70mg weekly dose)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
710
![Page 711: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/711.jpg)
Microdot TestProducts Affected
• MICRODOT TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
711
![Page 712: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/712.jpg)
Microgestin 1.5/30Products Affected
• MICROGESTIN 1.5/30
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
712
![Page 713: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/713.jpg)
Microgestin 1/20Products Affected
• MICROGESTIN 1/20
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
713
![Page 714: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/714.jpg)
Microgestin FE 1.5/30Products Affected
• MICROGESTIN FE 1.5/30
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
714
![Page 715: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/715.jpg)
Microgestin FE 1/20Products Affected
• MICROGESTIN FE 1/20
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
715
![Page 716: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/716.jpg)
MimveyProducts Affected
• MIMVEY
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
716
![Page 717: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/717.jpg)
MircetteProducts Affected
• MIRCETTE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
717
![Page 718: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/718.jpg)
Mirena (52 MG)Products Affected
• MIRENA (52 MG)
QL Criteria 1 IUD Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
718
![Page 719: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/719.jpg)
MirtazapineProducts Affected
• mirtazapine oral
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
719
![Page 720: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/720.jpg)
ModafinilProducts Affected
• modafinil
PA Criteria Criteria Details
Covered UsesExcessive daytime sleepiness associated with narcolepsy, Excessive daytime sleepiness associated with obstructive sleep apnea/hypopnea syndrome (OSAHS), shift work sleep disorder (SWSD)
Exclusion Criteria Modafinil is not indicated to treat side effects caused by other medications.
Required Medical Information
FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH NARCOLEPSY: Documentation of diagnostic testing and clinical notations supporting diagnosis of Narcolepsy, such as MSLT, clinical progress notes, etc. (Failure to adequately support the diagnosis of narcolepsy may result in denial of coverage), and the patient has failed an adequate trial of at least TWO of the following immediate release stimulants (all available generically): Dexedrine, Ritalin, or Adderall. FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH OBSTRUCTIVE SLEEP APNEA: The prescribing physician is a sleep specialist, ear, nose and throat, neurologist or pulmonologist or has obtained a consult from a sleep specialist, and a Standard Diagnostic Nocturnal Polysomnography (NPSG) has confirmed the diagnosis of OSA, and the patient has received nasal continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) for at least 1 month, and CPAP or BIPAP therapy will be continued on a routine basis in combination with modafinil therapy, and the daytime fatigue is significantly impacting, impairing, or compromising the patient's ability to function normally, and the prescribing physician has established a patient care plan to treat the cause of OSA in conjunction with treating the daily fatigue
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
The plan also requires an unresponsive 2-week trial of 200mg per day dose before a 400mg per dose is authorized. (Doses up to 400mg/day given as a single dose have been well tolerated, but there is no consistent evidence that this dose confers additional benefit beyond that of the 200mg dose.)
QL Criteria 1 tablet Per 1 day
2016 Innovation Health Leap Drug GuideLast update 12/2016
720
![Page 721: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/721.jpg)
Notes/References
Revision DatePrior Authorization: November 09, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
721
![Page 722: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/722.jpg)
Modicon (28)Products Affected
• MODICON (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
722
![Page 723: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/723.jpg)
Monoclate-PProducts Affected
• MONOCLATE-P
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
723
![Page 724: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/724.jpg)
Mono-LinyahProducts Affected
• MONO-LINYAH
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
724
![Page 725: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/725.jpg)
Montelukast SodiumProducts Affected
• montelukast sodium oral
QL Criteria 1 pack Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
725
![Page 726: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/726.jpg)
Montelukast SodiumProducts Affected
• montelukast sodium oral
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
726
![Page 727: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/727.jpg)
Morphine Sulfate ERProducts Affected
• morphine sulfate er oral capsule extended release 24 hour
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
727
![Page 728: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/728.jpg)
Morphine Sulfate ER BeadsProducts Affected
• morphine sulfate er beads oral capsule extended release 24 hour 90 mg, 120 mg, 75 mg, 45 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
728
![Page 729: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/729.jpg)
MozobilProducts Affected
• MOZOBIL
PA Criteria Criteria Details
Covered UsesMobilizing hematopoeitic stem cells to peripheral blood for the purpose of collection and subsequent transplantation in patients with non-Hodgkins lymphoma and multiple myeloma
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 YEAR
Other Criteria
Notes/References
Revision DatePrior Authorization: April 13, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
729
![Page 730: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/730.jpg)
MultaqProducts Affected
• MULTAQ
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
730
![Page 731: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/731.jpg)
MyGlucoHealth TestProducts Affected
• MYGLUCOHEALTH TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
731
![Page 732: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/732.jpg)
MyoblocProducts Affected
• MYOBLOC
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/botulinum_toxin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
732
![Page 733: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/733.jpg)
MyorisanProducts Affected
• MYORISAN ORAL CAPSULE 20 MG, 40 MG, 10 MG
ST Criteria Documented step through MINOCYCLINE OR DOXYCYCLINE
QL Criteria 2 capsules Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
733
![Page 734: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/734.jpg)
MyrbetriqProducts Affected
• MYRBETRIQ
ST Criteria Documented step through OXYBUTYNIN OR TROSPIUM IR
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
734
![Page 735: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/735.jpg)
MytesiProducts Affected
• MYTESI
PA Criteria Criteria Details
Covered Uses Noninfectious diarrhea associated with HIV/AIDS infection
Exclusion CriteriaDiarrhea of infectious origin confirmed by diagnostic tests e.g. stool sample, blood culture, radiographic imaging, Diarrhea-predominant irritable bowel diseases such as Crohn's disease and ulcerative colitis
Required Medical Information
Diagnosis of noninfectious diarrhea associated with HIV/AIDS infection, currently taking antiviral therapy with adherence 80% or greater, and documentation of unsatisfactory effects with, intolerability to, or inability to take at least one antimotility agent such as Lomotil (atropine/diphenoxylate) or Imodium (loperamide).
Age Restrictions 18 Years of age or greater
Prescriber Restrictions
Gastroenterologist
Coverage Duration
6 months
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: December 02, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
735
![Page 736: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/736.jpg)
MyzilraProducts Affected
• MYZILRA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
736
![Page 737: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/737.jpg)
Naftifine HClProducts Affected
• naftifine hcl
ST Criteria Documented step through CLOTRIMAZOLE AND ECONAZOLE 1%
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
737
![Page 738: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/738.jpg)
NaftinProducts Affected
• NAFTIN EXTERNAL GEL 1 %
ST Criteria Documented step through CLOTRIMAZOLE AND ECONAZOLE 1%
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
738
![Page 739: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/739.jpg)
NaglazymeProducts Affected
• NAGLAZYME
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
739
![Page 740: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/740.jpg)
Naratriptan HClProducts Affected
• naratriptan hcl
QL Criteria 9 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
740
![Page 741: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/741.jpg)
NataziaProducts Affected
• NATAZIA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
741
![Page 742: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/742.jpg)
Necon 0.5/35 (28)Products Affected
• NECON 0.5/35 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
742
![Page 743: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/743.jpg)
Necon 1/35 (28)Products Affected
• NECON 1/35 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
743
![Page 744: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/744.jpg)
Necon 1/50 (28)Products Affected
• NECON 1/50 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
744
![Page 745: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/745.jpg)
Necon 10/11 (28)Products Affected
• NECON 10/11 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
745
![Page 746: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/746.jpg)
NeulastaProducts Affected
• NEULASTA SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/GCSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: November 08, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
746
![Page 747: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/747.jpg)
Neulasta Delivery KitProducts Affected
• NEULASTA DELIVERY KIT SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/GCSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: November 08, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
747
![Page 748: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/748.jpg)
NeupogenProducts Affected
• NEUPOGEN INJECTION • NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML, 300 MCG/ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/GCSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: November 08, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
748
![Page 749: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/749.jpg)
NeuproProducts Affected
• NEUPRO
ST Criteria Documented step through TWO of the following: GABAPENTIN, ROPINIROLE, PRAMIPEXOLE (covered without trials of Parkinson's)
QL Criteria 1 patch Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
749
![Page 750: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/750.jpg)
Neutek 2Tek Glucose/PressureProducts Affected
• NEUTEK 2TEK GLUCOSE/PRESSURE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
750
![Page 751: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/751.jpg)
Neutek 2Tek TestProducts Affected
• NEUTEK 2TEK TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
751
![Page 752: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/752.jpg)
Nevirapine ERProducts Affected
• nevirapine er oral tablet extended release 24 hr* 100 mg
QL Criteria 3 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
752
![Page 753: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/753.jpg)
Nevirapine ERProducts Affected
• nevirapine er oral tablet extended release 24 hr* 400 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
753
![Page 754: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/754.jpg)
NexAVARProducts Affected
• NEXAVAR
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
754
![Page 755: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/755.jpg)
NexIUMProducts Affected
• NEXIUM ORAL PACKET
PA Criteria Criteria Details
Covered Uses
Diagnosis of Zollinger-Ellison syndrome, Uncomplicated gastroesophageal reflux desease (Gerd) with breakthrough symptoms, Complicated GERD and other higher risk conditions such as feflux-associated laryngitis, recent gastroinestinal bleed, grade 3 or 4 erosive esophagitis, or GERD exacerbated asthma.
Exclusion Criteria
Non-Covered uses include uses not approved by the FDA, or if use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use). Quantity levels exceeding the quantity limitations on PPIs, Dexilant dosing exceeding 60mg/day
Required Medical Information
Rabeprazole up to 20 mg/day, Dexilant up to 60 mg/day, and Nexium up to 40 mg/day are available with prior-authorization when the following criteria is met: Step through Prilosec OTC/omeprazole, Prevacid 24H OTC, and pantoprazole. High Dose Nexium, Rabeprazole and Prevacid solutabs are available with prior-authorization when the following criteria is met: Nexium up to 80mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Rabeprazole up to 40mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Prevacid solutabs up to 60mg/day for members greater than 1 year old with documentation of: inability to swallow tablets/capsules and step through ONE of the following: 80mg/day of omeprazole (capsules may be opened and sprinkled on 1 tablespoon of applesauce), or 60mg/day of Prevacid 24H OTC (capsule may be opened and sprinkled on 1 tablespoon of applesauce, Ensure pudding, cottage cheese, yogurt, or strained pears, or emptied into 60mL of apple juice, orange juice, or tomato juice )
Age Restrictions
Prescriber Restrictions
Coverage Duration
Short Term course of high dose PPI 3-6 months. Long term course up to 1 Year.
2016 Innovation Health Leap Drug GuideLast update 12/2016
755
![Page 756: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/756.jpg)
PA Criteria Criteria Details
Other Criteria
A step through one of these high dose therapies (80mg/day of Prilosec OTC/omeprazole or pantoprazole, OR 60mg/day of Prevacid 24H OTC) is required even if the member was previously approved for Rabeprazole, Prevacid solutabs, or Nexium at standard dosing. Exceptions may be considered if there is documentation of intolerance, e.g., side-effects or allergies to Prilosec OTC/omeprazole, pantoprazole, and Prevacid 24H OTC.
QL Criteria 1 pack Per 1 day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
756
![Page 757: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/757.jpg)
Nexium 24HRProducts Affected
• NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
757
![Page 758: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/758.jpg)
NexplanonProducts Affected
• NEXPLANON
QL Criteria 1 implant Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
758
![Page 759: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/759.jpg)
Next Choice One DoseProducts Affected
• NEXT CHOICE ONE DOSE
QL Criteria 1 tablet Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
759
![Page 760: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/760.jpg)
Nicoderm CQProducts Affected
• NICODERM CQ
QL Criteria 1 patch Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
760
![Page 761: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/761.jpg)
NicotineProducts Affected
• nicotine transdermal patch 24 hr
QL Criteria 1 patch Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
761
![Page 762: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/762.jpg)
Nicotine Step 1Products Affected
• nicotine step 1
QL Criteria 1 patch Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
762
![Page 763: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/763.jpg)
Nicotine Step 2Products Affected
• nicotine step 2
QL Criteria 1 patch Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
763
![Page 764: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/764.jpg)
Nicotine Step 3Products Affected
• nicotine step 3
QL Criteria 1 patch Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
764
![Page 765: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/765.jpg)
NicotrolProducts Affected
• NICOTROL
QL Criteria 3 boxes-504 crtrg Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
765
![Page 766: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/766.jpg)
Nicotrol NSProducts Affected
• NICOTROL NS
QL Criteria 4 bottles Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
766
![Page 767: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/767.jpg)
Nifediac CCProducts Affected
• NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
767
![Page 768: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/768.jpg)
Nifediac CCProducts Affected
• NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
768
![Page 769: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/769.jpg)
Nifedical XLProducts Affected
• NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
769
![Page 770: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/770.jpg)
Nifedical XLProducts Affected
• NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
770
![Page 771: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/771.jpg)
NIFEdipine ERProducts Affected
• nifedipine er oral tablet extended release 24 hr* 30 mg, 90 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
771
![Page 772: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/772.jpg)
NIFEdipine ERProducts Affected
• nifedipine er oral tablet extended release 24 hr* 60 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
772
![Page 773: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/773.jpg)
NIFEdipine ER Osmotic ReleaseProducts Affected
• nifedipine er osmotic release oral tablet extended release 24 hr* 90 mg, 30 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
773
![Page 774: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/774.jpg)
NIFEdipine ER Osmotic ReleaseProducts Affected
• nifedipine er osmotic release oral tablet extended release 24 hr* 60 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
774
![Page 775: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/775.jpg)
NikkiProducts Affected
• NIKKI
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
775
![Page 776: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/776.jpg)
Nisoldipine ERProducts Affected
• nisoldipine er oral tablet extended release 24 hr* 20 mg, 25.5 mg, 40 mg, 8.5 mg, 17 mg, 34 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
776
![Page 777: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/777.jpg)
Nisoldipine ERProducts Affected
• nisoldipine er oral tablet extended release 24 hr* 30 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
777
![Page 778: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/778.jpg)
NitroglycerinProducts Affected
• nitroglycerin translingual solution
QL Criteria 12 grams Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
778
![Page 779: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/779.jpg)
Nora-BEProducts Affected
• NORA-BE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
779
![Page 780: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/780.jpg)
NorethindroneProducts Affected
• norethindrone oral
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
780
![Page 781: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/781.jpg)
Norinyl 1+35 (28)Products Affected
• NORINYL 1+35 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
781
![Page 782: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/782.jpg)
Norinyl 1+50 (28)Products Affected
• NORINYL 1+50 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
782
![Page 783: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/783.jpg)
NorlyrocProducts Affected
• NORLYROC
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
783
![Page 784: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/784.jpg)
Nortrel 0.5/35 (28)Products Affected
• NORTREL 0.5/35 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
784
![Page 785: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/785.jpg)
Nortrel 1/35 (21)Products Affected
• NORTREL 1/35 (21)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
785
![Page 786: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/786.jpg)
Nortrel 1/35 (28)Products Affected
• NORTREL 1/35 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
786
![Page 787: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/787.jpg)
Nova Max Blood Glucose SystemProducts Affected
• NOVA MAX BLOOD GLUCOSE SYSTEM DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
787
![Page 788: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/788.jpg)
Nova Max Glucose TestProducts Affected
• NOVA MAX GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
788
![Page 789: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/789.jpg)
NovarelProducts Affected
• NOVAREL
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
789
![Page 790: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/790.jpg)
NovoeightProducts Affected
• NOVOEIGHT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
790
![Page 791: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/791.jpg)
NovoLIN 70/30Products Affected
• NOVOLIN 70/30
ST Criteria Documented step through HUMULIN Product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
791
![Page 792: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/792.jpg)
NovoLIN 70/30 ReliOnProducts Affected
• NOVOLIN 70/30 RELION
ST Criteria Documented step through HUMULIN Product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
792
![Page 793: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/793.jpg)
NovoLIN NProducts Affected
• NOVOLIN N
ST Criteria Documented step through HUMULIN Product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
793
![Page 794: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/794.jpg)
NovoLIN N ReliOnProducts Affected
• NOVOLIN N RELION
ST Criteria Documented step through HUMULIN Product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
794
![Page 795: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/795.jpg)
NovoLIN RProducts Affected
• NOVOLIN R
ST Criteria Documented step through HUMULIN Product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
795
![Page 796: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/796.jpg)
NovoLIN R ReliOnProducts Affected
• NOVOLIN R RELION
ST Criteria Documented step through HUMULIN Product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
796
![Page 797: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/797.jpg)
NovoLOGProducts Affected
• NOVOLOG
ST Criteria Documented step through HUMALOG product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
797
![Page 798: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/798.jpg)
NovoLOG FlexPenProducts Affected
• NOVOLOG FLEXPEN SUBCUTANEOUS*
ST Criteria Documented step through HUMALOG product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
798
![Page 799: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/799.jpg)
NovoLOG Mix 70/30Products Affected
• NOVOLOG MIX 70/30
ST Criteria Documented step through HUMALOG product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
799
![Page 800: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/800.jpg)
NovoLOG Mix 70/30 FlexPenProducts Affected
• NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS*
ST Criteria Documented step through HUMALOG product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
800
![Page 801: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/801.jpg)
NovoLOG PenFillProducts Affected
• NOVOLOG PENFILL SUBCUTANEOUS*
ST Criteria Documented step through HUMALOG product
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
801
![Page 802: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/802.jpg)
NovoSevenProducts Affected
• NOVOSEVEN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
802
![Page 803: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/803.jpg)
NovoSeven RTProducts Affected
• NOVOSEVEN RT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
803
![Page 804: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/804.jpg)
NoxafilProducts Affected
• NOXAFIL ORAL SUSPENSION
PA Criteria Criteria Details
Covered UsesProphylaxis of Invasive Aspergillosis, prophylaxis of invasive candidiasis, treatment of oropharyngeal candidiasis in patients with disease refractory
Exclusion Criteria
Noxafil is NOT covered for members who are pursuing for prophylaxis of invasive aspergillosis or candidiasis who are not severely immunocompromised, for patients less that 13 years of age, patients without refractory disease to first-line antifungal agents, concomitant use with ergot alkaloids, simvastatin, or sirolimus, or concomitant use with CYP3A4 substrates such as, pimozide and quinidine.
Required Medical Information
Noxafil is covered for members who meet any ONE of the following criteria: (1) Prophylaxis of Invasive Aspergillosis in severely immunocompromised patients with active disease, (2) Prophylaxis of Invasive Candidiasis in severely immunocompromised patients with a history of developing invasive candidiasis refractory to fluconazole or who are intolerant to fluconazole, or (3) Treatment of Oropharyngeal Candidiasis in patients with disease refractory to fluconazole or itraconazole.
Age Restrictions 13 years of age or greater
Prescriber Restrictions
Coverage Duration
Invasive Aspergillosis/Candidiasis prophylaxis- 3 months, Oropharyngeal Candidiasis-13 days
Other Criteria
Refractory fungal infection is defined as a previous occurrence of disease which failed to improve or respond to a standard course of antifungal therapy. Patients started on Noxafil as an inpatient will be allowed to continue therapy on an outpatient basis without interruption. Initial therapy of one 105ml bottle (7-day supply) will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
804
![Page 805: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/805.jpg)
NucyntaProducts Affected
• NUCYNTA
PA Criteria Criteria Details
Covered Uses Moderate to severe pain
Exclusion Criteria Known or suspicious misuse of medications or illicit drug use.
Required Medical Information
Documented progression through the World Health Organization analgesic ladder, and step through, contraindication, or intolerance to two (2) alternative formulary immediate release opioids. Alternatives include morphine, oxycodone, hydromorphone.
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 3 years
Other Criteria
QL Criteria 6 tablets Per 1 day
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
805
![Page 806: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/806.jpg)
Nucynta ERProducts Affected
• NUCYNTA ER
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
806
![Page 807: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/807.jpg)
NuedextaProducts Affected
• NUEDEXTA
PA Criteria Criteria Details
Covered UsesTreatment of pseudobulbar affect in patients with amyotrophic lateral sclerosis (ALS) OR multiple sclerosis (MS).
Exclusion CriteriaTreatment in other types of emotional lability (i.e. Alzheimers disease and other dementias).
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
807
![Page 808: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/808.jpg)
NulojixProducts Affected
• NULOJIX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/immunosuppressives.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: February 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
808
![Page 809: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/809.jpg)
NuvaRingProducts Affected
• NUVARING
QL Criteria 1 ring Per 28 dayss
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
809
![Page 810: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/810.jpg)
NuwiqProducts Affected
• NUWIQ
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
810
![Page 811: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/811.jpg)
OcellaProducts Affected
• OCELLA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
811
![Page 812: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/812.jpg)
OctagamProducts Affected
• OCTAGAM INTRAVENOUS* SOLUTION 1 GM/20ML, 10 GM/200ML, 2 GM/20ML, 20 GM/200ML, 2.5 GM/50ML, 25 GM/500ML, 5 GM/100ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
812
![Page 813: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/813.jpg)
Octreotide AcetateProducts Affected
• octreotide acetate injection solution 500 mcg/ml, 100 mcg/ml, 1000 mcg/ml, 50 mcg/ml, 200 mcg/ml
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/Sandostatin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
813
![Page 814: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/814.jpg)
OdefseyProducts Affected
• ODEFSEY
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
814
![Page 815: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/815.jpg)
OgestrelProducts Affected
• OGESTREL
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
815
![Page 816: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/816.jpg)
OLANZapineProducts Affected
• olanzapine oral tablet 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
• olanzapine oral tablet dispersible
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
816
![Page 817: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/817.jpg)
OLANZapineProducts Affected
• olanzapine oral tablet 2.5 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
817
![Page 818: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/818.jpg)
OLANZapine-FLUoxetine HClProducts Affected
• olanzapine-fluoxetine hcl
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
818
![Page 819: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/819.jpg)
OleptroProducts Affected
• OLEPTRO
ST Criteria Documented step through TRAZADONE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
819
![Page 820: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/820.jpg)
Omega-3-acid Ethyl EstersProducts Affected
• omega-3-acid ethyl esters
QL Criteria 4 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
820
![Page 821: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/821.jpg)
Omeprazole-Sodium BicarbonateProducts Affected
• omeprazole-sodium bicarbonate oral capsule20-1100 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
821
![Page 822: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/822.jpg)
OmnarisProducts Affected
• OMNARIS
ST Criteria Documented step through FLUTICASONE PROPIONATE AND FLUNISOLIDE
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
822
![Page 823: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/823.jpg)
OmnitropeProducts Affected
• OMNITROPE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
823
![Page 824: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/824.jpg)
On Call Plus Blood GlucoseProducts Affected
• ON CALL PLUS BLOOD GLUCOSE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
824
![Page 825: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/825.jpg)
On Call Vivid Blood GlucoseProducts Affected
• ON CALL VIVID BLOOD GLUCOSE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
825
![Page 826: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/826.jpg)
OndansetronProducts Affected
• ondansetron
QL Criteria 12 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
826
![Page 827: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/827.jpg)
Ondansetron HClProducts Affected
• ondansetron hcl oral tablet 8 mg
QL Criteria 60 tablets Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
827
![Page 828: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/828.jpg)
Ondansetron HClProducts Affected
• ondansetron hcl oral solution
QL Criteria 1 bottle Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
828
![Page 829: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/829.jpg)
Ondansetron HClProducts Affected
• ondansetron hcl oral tablet 24 mg, 4 mg
QL Criteria 12 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
829
![Page 830: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/830.jpg)
OneTouch TestProducts Affected
• ONETOUCH TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
830
![Page 831: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/831.jpg)
OneTouch Ultra BlueProducts Affected
• ONETOUCH ULTRA BLUE
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
831
![Page 832: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/832.jpg)
OneTouch VerioProducts Affected
• ONETOUCH VERIO IN VITRO STRIP
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
832
![Page 833: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/833.jpg)
OnfiProducts Affected
• ONFI ORAL SUSPENSION
PA Criteria Criteria Details
Covered Uses Adjunctive treatment of seizures associated with Lennox-Gastaut syndrome
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
833
![Page 834: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/834.jpg)
OnfiProducts Affected
• ONFI ORAL TABLET 10 MG, 20 MG
PA Criteria Criteria Details
Covered Uses Adjunctive treatment of seizures associated with Lennox-Gastaut syndrome
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
834
![Page 835: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/835.jpg)
OnglyzaProducts Affected
• ONGLYZA
ST Criteria Documented step through METFORMIN 1500MG/day
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
835
![Page 836: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/836.jpg)
Opana ERProducts Affected
• OPANA ER ORAL
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
836
![Page 837: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/837.jpg)
OpsumitProducts Affected
• OPSUMIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
837
![Page 838: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/838.jpg)
Optium TestProducts Affected
• OPTIUM TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
838
![Page 839: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/839.jpg)
OptiumEZ TestProducts Affected
• OPTIUMEZ TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
839
![Page 840: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/840.jpg)
OravigProducts Affected
• ORAVIG
PA Criteria Criteria Details
Covered Uses Infection
Exclusion Criteria
Required Medical Information
Have documented step through fluconazole, AND nystatin or clotrimazole troche
Age Restrictions Less than 16 years old
Prescriber Restrictions
Coverage Duration
6 months
Other Criteria
QL Criteria 14 tablets Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
840
![Page 841: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/841.jpg)
OrenciaProducts Affected
• ORENCIA SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Orencia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Orencia.html
QL Criteria 4 syringes Per 1 month
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
841
![Page 842: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/842.jpg)
OrenciaProducts Affected
• ORENCIA INTRAVENOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Orencia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Orencia.html
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
842
![Page 843: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/843.jpg)
Orencia ClickJectProducts Affected
• ORENCIA CLICKJECT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Orencia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Orencia.html
QL Criteria 4 syringes Per 1 month
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
843
![Page 844: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/844.jpg)
OrkambiProducts Affected
• ORKAMBI
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/cystic_fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: December 21, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
844
![Page 845: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/845.jpg)
OrkambiProducts Affected
• ORKAMBI
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/cystic_fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 EA Per 1 Day
Notes/References
Revision DatePrior Authorization: December 21, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
845
![Page 846: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/846.jpg)
OrsythiaProducts Affected
• ORSYTHIA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
846
![Page 847: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/847.jpg)
Ortho MicronorProducts Affected
• ORTHO MICRONOR
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
847
![Page 848: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/848.jpg)
Ortho Tri-Cyclen (28)Products Affected
• ORTHO TRI-CYCLEN (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
848
![Page 849: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/849.jpg)
Ortho Tri-Cyclen LoProducts Affected
• ORTHO TRI-CYCLEN LO
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
849
![Page 850: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/850.jpg)
Ortho-Cept (28)Products Affected
• ORTHO-CEPT (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
850
![Page 851: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/851.jpg)
Ortho-Cyclen (28)Products Affected
• ORTHO-CYCLEN (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
851
![Page 852: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/852.jpg)
Ortho-Novum 1/35 (28)Products Affected
• ORTHO-NOVUM 1/35 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
852
![Page 853: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/853.jpg)
Ortho-Novum 7/7/7 (28)Products Affected
• ORTHO-NOVUM 7/7/7 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
853
![Page 854: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/854.jpg)
Ovcon-35 (28)Products Affected
• OVCON-35 (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
854
![Page 855: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/855.jpg)
OvidrelProducts Affected
• OVIDREL
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
855
![Page 856: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/856.jpg)
Oxtellar XRProducts Affected
• OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 600 MG
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
856
![Page 857: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/857.jpg)
Oxtellar XRProducts Affected
• OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
857
![Page 858: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/858.jpg)
Oxybutynin ChlorideProducts Affected
• oxybutynin chloride oral tablet
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
858
![Page 859: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/859.jpg)
Oxybutynin Chloride ERProducts Affected
• oxybutynin chloride er
ST Criteria Documented step through OXYBUTYNIN OR TROSPIUM IR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
859
![Page 860: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/860.jpg)
Oxycodone-IbuprofenProducts Affected
• oxycodone-ibuprofen
QL Criteria 28 tablets Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
860
![Page 861: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/861.jpg)
OxyCONTINProducts Affected
• OXYCONTIN ORAL
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
QL Criteria 4 tablets Per 1 Day
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
861
![Page 862: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/862.jpg)
Oxymorphone HClProducts Affected
• oxymorphone hcl
PA Criteria Criteria Details
Covered Uses Moderate to severe pain
Exclusion Criteria
Oxymorphone is not covered for members with no documented progression through the World Health Organization analgesic ladder, who have not tried and failed three (2) alternative formulary opioids, or who have a known hypersensitivity to morphine analogs (e.g. codeine).
Required Medical Information
Documented progression through the World Health Organization analgesic ladder and step through, contraindication, or intolerance to two (2) alternative formulary immediate release opioids. Alternatives include morphine, oxycodone, hydromorphone.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
862
![Page 863: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/863.jpg)
Oxymorphone HCl ERProducts Affected
• oxymorphone hcl er oral tablet extended release 12 hr* 10 mg
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
863
![Page 864: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/864.jpg)
Oxymorphone HCl ERProducts Affected
• oxymorphone hcl er oral tablet extended release 12 hr* 40 mg, 5 mg, 7.5 mg, 15 mg, 20 mg
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
864
![Page 865: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/865.jpg)
OxyMORphone HCl ERProducts Affected
• oxymorphone hcl er oral tablet extended release 12 hr* 30 mg
PA Criteria Criteria Details
Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.
Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder
Required Medical Information
For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
up to 1 year
Other Criteria
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
865
![Page 866: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/866.jpg)
Paliperidone ERProducts Affected
• paliperidone er oral tablet extended release 24 hr* 1.5 mg, 9 mg, 3 mg
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
866
![Page 867: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/867.jpg)
Paliperidone ERProducts Affected
• paliperidone er oral tablet extended release 24 hr* 6 mg
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
QL Criteria 2 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
867
![Page 868: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/868.jpg)
PancreazeProducts Affected
• PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 4200-10000 UNIT, 10500-25000 UNIT, 16800-40000 UNIT, 21000-37000 UNIT
PA Criteria Criteria Details
Covered Uses Exocrine pancreatic Insufficiency
Exclusion CriteriaUses not approved by the FDA, uses unapproved and not supported by the literature or evidence as an accepted off-label use. (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Diagnosis of exocrine pancreatic insufficiency due to cystic fibrosis or other conditions and a documented trial of two weeks of Zenpep.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References Annual Review: 07/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
868
![Page 869: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/869.jpg)
Pancrelipase (Lip-Prot-Amyl)Products Affected
• pancrelipase (lip-prot-amyl)
PA Criteria Criteria Details
Covered Uses Exocrine pancreatic Insufficiency
Exclusion CriteriaUses not approved by the FDA, uses unapproved and not supported by the literature or evidence as an accepted off-label use. (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Diagnosis of exocrine pancreatic insufficiency due to cystic fibrosis or other conditions and a documented trial of two weeks of Zenpep.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References Annual Review: 07/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
869
![Page 870: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/870.jpg)
Paragard Intrauterine CopperProducts Affected
• PARAGARD INTRAUTERINE COPPER
QL Criteria 1 IUD Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
870
![Page 871: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/871.jpg)
ParicalcitolProducts Affected
• paricalcitol oral
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
871
![Page 872: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/872.jpg)
PARoxetine HClProducts Affected
• paroxetine hcl oral tablet 10 mg, 20 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
872
![Page 873: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/873.jpg)
PARoxetine HClProducts Affected
• paroxetine hcl oral tablet 30 mg, 40 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
873
![Page 874: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/874.jpg)
PARoxetine HCl ERProducts Affected
• paroxetine hcl er oral tablet extended release 24 hr* 25 mg
ST Criteria Documented step through paroxetine
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
874
![Page 875: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/875.jpg)
PARoxetine HCl ERProducts Affected
• paroxetine hcl er oral tablet extended release 24 hr* 37.5 mg, 12.5 mg
ST Criteria Documented step through paroxetine
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
875
![Page 876: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/876.jpg)
PEG 3350/ElectrolytesProducts Affected
• peg 3350/electrolytes
QL Criteria 4 liters Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
876
![Page 877: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/877.jpg)
PEG-3350/ElectrolytesProducts Affected
• peg-3350/electrolytes
QL Criteria 4 liters Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
877
![Page 878: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/878.jpg)
PegasysProducts Affected
• PEGASYS SUBCUTANEOUS* SOLUTION
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
878
![Page 879: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/879.jpg)
Pegasys ProClickProducts Affected
• PEGASYS PROCLICK
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
879
![Page 880: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/880.jpg)
Peg-IntronProducts Affected
• PEG-INTRON
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
880
![Page 881: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/881.jpg)
Peg-Intron RedipenProducts Affected
• PEG-INTRON REDIPEN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
881
![Page 882: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/882.jpg)
Peg-Intron Redipen Pak 4Products Affected
• PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS* KIT 50 MCG/0.5ML, 150 MCG/0.5ML, 120 MCG/0.5ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
882
![Page 883: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/883.jpg)
PentasaProducts Affected
• PENTASA ORAL CAPSULE EXTENDED RELEASE* 250 MG
ST Criteria Documented failure, contraindication or intolerance to Apriso
QL Criteria 16 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
883
![Page 884: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/884.jpg)
PentasaProducts Affected
• PENTASA ORAL CAPSULE EXTENDED RELEASE* 500 MG
ST Criteria Documented failure, contraindication or intolerance to Apriso
QL Criteria 8 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
884
![Page 885: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/885.jpg)
PerforomistProducts Affected
• PERFOROMIST
PA Criteria Criteria Details
Covered Uses Chronic Obstructive Pulmonary Disease (COPD)
Exclusion Criteria
Required Medical Information
Documented physical limitation that prevents the use of a non-nebulized long-acting bronchodilator with or without use of a spacer
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 4 milliliters Per 1 day
Notes/References Annual Review: 07/2016
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
885
![Page 886: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/886.jpg)
PertzyeProducts Affected
• PERTZYE
PA Criteria Criteria Details
Covered Uses Exocrine pancreatic Insufficiency
Exclusion CriteriaUses not approved by the FDA, uses unapproved and not supported by the literature or evidence as an accepted off-label use. (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Diagnosis of exocrine pancreatic insufficiency due to cystic fibrosis or other conditions and a documented trial of two weeks of Zenpep.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References Annual Review: 07/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
886
![Page 887: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/887.jpg)
Pharmacist Choice AutocodeProducts Affected
• PHARMACIST CHOICE AUTOCODE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
887
![Page 888: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/888.jpg)
PhilithProducts Affected
• PHILITH
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
888
![Page 889: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/889.jpg)
PicatoProducts Affected
• PICATO EXTERNAL GEL 0.05 %
QL Criteria 2 unit dose tubes Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
889
![Page 890: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/890.jpg)
PicatoProducts Affected
• PICATO EXTERNAL GEL 0.015 %
QL Criteria 3 unit dose tubes Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
890
![Page 891: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/891.jpg)
Pioglitazone HClProducts Affected
• pioglitazone hcl
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
891
![Page 892: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/892.jpg)
Pioglitazone HCl-GlimepirideProducts Affected
• pioglitazone hcl-glimepiride
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
892
![Page 893: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/893.jpg)
Pioglitazone HCl-Metformin HClProducts Affected
• pioglitazone hcl-metformin hcl
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
893
![Page 894: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/894.jpg)
Plan B One-StepProducts Affected
• PLAN B ONE-STEP
QL Criteria 1 tablet Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
894
![Page 895: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/895.jpg)
PlegridyProducts Affected
• PLEGRIDY
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
QL Criteria 2 inj Per 28 Days
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
895
![Page 896: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/896.jpg)
Plegridy Starter PackProducts Affected
• PLEGRIDY STARTER PACK
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
QL Criteria 2 inj Per 28 Days
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
896
![Page 897: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/897.jpg)
PocketChem EZ TestProducts Affected
• POCKETCHEM EZ TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
897
![Page 898: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/898.jpg)
PomalystProducts Affected
• POMALYST
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
898
![Page 899: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/899.jpg)
Portia-28Products Affected
• PORTIA-28
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
899
![Page 900: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/900.jpg)
PotigaProducts Affected
• POTIGA ORAL TABLET 200 MG, 400 MG, 300 MG
PA Criteria Criteria Details
Covered Uses partial-onset seizures
Exclusion Criteria
Required Medical Information
documented diagnosis of partial-onset seizures
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 3 tablets Per 1 day
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
900
![Page 901: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/901.jpg)
PotigaProducts Affected
• POTIGA ORAL TABLET 50 MG
PA Criteria Criteria Details
Covered Uses partial-onset seizures
Exclusion Criteria
Required Medical Information
documented diagnosis of partial-onset seizures
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 6 tablets Per 1 day
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
901
![Page 902: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/902.jpg)
PraluentProducts Affected
• PRALUENT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/PCSK9.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 syringes Per 28 Days
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
902
![Page 903: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/903.jpg)
Pramipexole Dihydrochloride ERProducts Affected
• pramipexole dihydrochloride er
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
903
![Page 904: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/904.jpg)
Pravastatin SodiumProducts Affected
• pravastatin sodium
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
904
![Page 905: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/905.jpg)
Precision PCxProducts Affected
• PRECISION PCX
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
905
![Page 906: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/906.jpg)
Precision PCX Plus TestProducts Affected
• PRECISION PCX PLUS TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
906
![Page 907: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/907.jpg)
Precision Point of Care TestProducts Affected
• PRECISION POINT OF CARE TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
907
![Page 908: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/908.jpg)
Precision QID TestProducts Affected
• PRECISION QID TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
908
![Page 909: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/909.jpg)
Precision Sof-Tact TestProducts Affected
• PRECISION SOF-TACT TEST
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
909
![Page 910: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/910.jpg)
Precision XtraProducts Affected
• PRECISION XTRA DEVICE
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
910
![Page 911: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/911.jpg)
Precision Xtra Blood GlucoseProducts Affected
• PRECISION XTRA BLOOD GLUCOSE
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
911
![Page 912: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/912.jpg)
Precision Xtra MonitorProducts Affected
• PRECISION XTRA MONITOR
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
912
![Page 913: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/913.jpg)
PrefestProducts Affected
• PREFEST
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
913
![Page 914: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/914.jpg)
PregnylProducts Affected
• PREGNYL
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
914
![Page 915: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/915.jpg)
PremarinProducts Affected
• PREMARIN ORAL
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
915
![Page 916: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/916.jpg)
PremphaseProducts Affected
• PREMPHASE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
916
![Page 917: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/917.jpg)
PremproProducts Affected
• PREMPRO
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
917
![Page 918: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/918.jpg)
PrevacidProducts Affected
• PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
918
![Page 919: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/919.jpg)
PrevifemProducts Affected
• PREVIFEM
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
919
![Page 920: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/920.jpg)
PrezistaProducts Affected
• PREZISTA ORAL TABLET 600 MG, 75 MG, 150 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
920
![Page 921: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/921.jpg)
PrezistaProducts Affected
• PREZISTA ORAL TABLET 800 MG
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
921
![Page 922: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/922.jpg)
PrezistaProducts Affected
• PREZISTA ORAL SUSPENSION
QL Criteria 12 milliliters Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
922
![Page 923: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/923.jpg)
PristiqProducts Affected
• PRISTIQ
PA Criteria Criteria Details
Covered Uses Major Depressive Disorder
Exclusion CriteriaPatients taking products containing venlafaxine concomitantly, patients taking MAOIs concomitantly, or for use in pediatrics.
Required Medical Information
Documentation of failure or unresponsiveness to THREE different antidepressants from at least two different therapeutic subclasses, or patient is a new member and has been receiving Pristiq therapy for more than 4 weeks.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
923
![Page 924: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/924.jpg)
PrivigenProducts Affected
• PRIVIGEN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
924
![Page 925: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/925.jpg)
ProAir HFAProducts Affected
• PROAIR HFA
ST Criteria Documented step through VENTOLIN HFA
QL Criteria 2 inhalers Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
925
![Page 926: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/926.jpg)
ProcritProducts Affected
• PROCRIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Erythropoiesis_Stimulating_Agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
926
![Page 927: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/927.jpg)
Prodigy AutoCode Blood GlucoseProducts Affected
• PRODIGY AUTOCODE BLOOD GLUCOSE DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
927
![Page 928: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/928.jpg)
Prodigy No Coding Blood GlucProducts Affected
• PRODIGY NO CODING BLOOD GLUC
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
928
![Page 929: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/929.jpg)
ProfilnineProducts Affected
• PROFILNINE INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
929
![Page 930: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/930.jpg)
Profilnine SDProducts Affected
• PROFILNINE SD
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
930
![Page 931: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/931.jpg)
Progesterone MicronizedProducts Affected
• progesterone micronized oral
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
931
![Page 932: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/932.jpg)
Prolastin-CProducts Affected
• PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/immunomodulators_CAP.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
932
![Page 933: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/933.jpg)
ProleukinProducts Affected
• PROLEUKIN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Interleukin%202.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: April 13, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
933
![Page 934: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/934.jpg)
ProliaProducts Affected
• PROLIA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
934
![Page 935: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/935.jpg)
PromactaProducts Affected
• PROMACTA ORAL TABLET 25 MG, 12.5 MG, 50 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/promacta.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
935
![Page 936: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/936.jpg)
Propafenone HCl ERProducts Affected
• propafenone hcl er
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
936
![Page 937: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/937.jpg)
Proventil HFAProducts Affected
• PROVENTIL HFA
ST Criteria Documented step through VENTOLIN HFA
QL Criteria 2 inhalers Per 1 month
Notes/References Annual Review: 03/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
937
![Page 938: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/938.jpg)
Pulmicort FlexhalerProducts Affected
• PULMICORT FLEXHALER
ST Criteria Documented step through QVAR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
938
![Page 939: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/939.jpg)
PulmozymeProducts Affected
• PULMOZYME
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/cystic_fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 ampules Per 1 day
Notes/References
Revision DatePrior Authorization: December 21, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
939
![Page 940: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/940.jpg)
QnaslProducts Affected
• QNASL
ST Criteria Documented step through FLUTICASONE PROPIONATE AND FLUNISOLIDE
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
940
![Page 941: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/941.jpg)
Qnasl ChildrensProducts Affected
• QNASL CHILDRENS
ST Criteria Documented step through FLUTICASONE PROPIONATE AND FLUNISOLIDE
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
941
![Page 942: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/942.jpg)
QuasenseProducts Affected
• QUASENSE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
942
![Page 943: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/943.jpg)
QUEtiapine FumarateProducts Affected
• quetiapine fumarate oral tablet 100 mg, 50 mg
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
943
![Page 944: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/944.jpg)
QUEtiapine FumarateProducts Affected
• quetiapine fumarate oral tablet 25 mg
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
944
![Page 945: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/945.jpg)
QUEtiapine FumarateProducts Affected
• quetiapine fumarate oral tablet 300 mg, 400 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
945
![Page 946: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/946.jpg)
QUEtiapine FumarateProducts Affected
• quetiapine fumarate oral tablet 200 mg
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
946
![Page 947: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/947.jpg)
Quillivant XRProducts Affected
• QUILLIVANT XR
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 12 milliliters Per 1 day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
947
![Page 948: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/948.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
948
![Page 949: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/949.jpg)
QuiNINE SulfateProducts Affected
• quinine sulfate oral
PA Criteria Criteria Details
Covered Uses Malaria, babesiosis
Exclusion Criteria
Qualaquin is NOT covered for use for leg cramps, in women who are pregnant, or in patients with cerebral malaria in combination with doxycycline, tetracycline, or clindamycin (members should be treated with IV quinine per CDC (not oral).
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
MALARIA - 7 days (42 capsules). BABESIOSIS - 10 days (60 capsules).
Other Criteria
QL Criteria 42 capsules Per 1 fill
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
949
![Page 950: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/950.jpg)
RA Blood Glucose MonitorProducts Affected
• ra blood glucose monitor
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
950
![Page 951: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/951.jpg)
RA TRUEtest TestProducts Affected
• RA TRUETEST TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
951
![Page 952: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/952.jpg)
RABEprazole SodiumProducts Affected
• rabeprazole sodium
PA Criteria Criteria Details
Covered Uses
Diagnosis of Zollinger-Ellison syndrome, Uncomplicated gastroesophageal reflux desease (Gerd) with breakthrough symptoms, Complicated GERD and other higher risk conditions such as feflux-associated laryngitis, recent gastroinestinal bleed, grade 3 or 4 erosive esophagitis, or GERD exacerbated asthma.
Exclusion Criteria
Non-Covered uses include uses not approved by the FDA, or if use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use). Quantity levels exceeding the quantity limitations on PPIs, Dexilant dosing exceeding 60mg/day
Required Medical Information
Rabeprazole up to 20 mg/day, Dexilant up to 60 mg/day, and Nexium up to 40 mg/day are available with prior-authorization when the following criteria is met: Step through Prilosec OTC/omeprazole, Prevacid 24H OTC, and pantoprazole. High Dose Nexium, Rabeprazole and Prevacid solutabs are available with prior-authorization when the following criteria is met: Nexium up to 80mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Rabeprazole up to 40mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Prevacid solutabs up to 60mg/day for members greater than 1 year old with documentation of: inability to swallow tablets/capsules and step through ONE of the following: 80mg/day of omeprazole (capsules may be opened and sprinkled on 1 tablespoon of applesauce), or 60mg/day of Prevacid 24H OTC (capsule may be opened and sprinkled on 1 tablespoon of applesauce, Ensure pudding, cottage cheese, yogurt, or strained pears, or emptied into 60mL of apple juice, orange juice, or tomato juice )
Age Restrictions
Prescriber Restrictions
Coverage Duration
Short Term course of high dose PPI 3-6 months. Long term course up to 1 Year.
2016 Innovation Health Leap Drug GuideLast update 12/2016
952
![Page 953: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/953.jpg)
PA Criteria Criteria Details
Other Criteria
A step through one of these high dose therapies (80mg/day of Prilosec OTC/omeprazole or pantoprazole, OR 60mg/day of Prevacid 24H OTC) is required even if the member was previously approved for Rabeprazole, Prevacid solutabs, or Nexium at standard dosing. Exceptions may be considered if there is documentation of intolerance, e.g., side-effects or allergies to Prilosec OTC/omeprazole, pantoprazole, and Prevacid 24H OTC.
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
953
![Page 954: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/954.jpg)
RajaniProducts Affected
• RAJANI
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
954
![Page 955: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/955.jpg)
RanexaProducts Affected
• RANEXA
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
955
![Page 956: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/956.jpg)
RavictiProducts Affected
• RAVICTI
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 12 bottles Per 1 month
Notes/References
Revision DatePrior Authorization: August 31, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
956
![Page 957: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/957.jpg)
RebetolProducts Affected
• REBETOL ORAL SOLUTION
QL Criteria 5 bottles Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
957
![Page 958: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/958.jpg)
RebifProducts Affected
• REBIF SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
958
![Page 959: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/959.jpg)
Rebif RebidoseProducts Affected
• REBIF REBIDOSE SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
959
![Page 960: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/960.jpg)
Rebif Rebidose Titration PackProducts Affected
• REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
960
![Page 961: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/961.jpg)
Rebif Titration PackProducts Affected
• REBIF TITRATION PACK SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
961
![Page 962: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/962.jpg)
ReclastProducts Affected
• RECLAST
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
962
![Page 963: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/963.jpg)
ReclipsenProducts Affected
• RECLIPSEN
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
963
![Page 964: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/964.jpg)
RecombinateProducts Affected
• RECOMBINATE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
964
![Page 965: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/965.jpg)
RectivProducts Affected
• RECTIV
QL Criteria 1 tube Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
965
![Page 966: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/966.jpg)
RefuAH Plus Blood Glucose TestProducts Affected
• REFUAH PLUS BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
966
![Page 967: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/967.jpg)
Relenza DiskhalerProducts Affected
• RELENZA DISKHALER
QL Criteria 40 disks Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
967
![Page 968: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/968.jpg)
ReliOn Confirm/micro TestProducts Affected
• RELION CONFIRM/MICRO TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
968
![Page 969: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/969.jpg)
ReliOn Prime MonitorProducts Affected
• RELION PRIME MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
969
![Page 970: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/970.jpg)
ReliOn Prime TestProducts Affected
• RELION PRIME TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
970
![Page 971: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/971.jpg)
ReliOn Ultima TestProducts Affected
• RELION ULTIMA TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
971
![Page 972: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/972.jpg)
RelistorProducts Affected
• RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML
PA Criteria Criteria Details
Covered UsesOpioid-induced constipation (OIC) in adults with chronic non-cancer pain, OIC in adults with advanced illness
Exclusion Criteria
Required Medical Information
Patients with advanced illness who are receiving palliative care, for the treatment of opioid-induced constipation when response to laxative therapy has not been sufficient.
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 Months
Other Criteria
QL Criteria 0.6 ml Per 1 Day
Notes/References
Revision DatePrior Authorization: September 09, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
972
![Page 973: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/973.jpg)
RelistorProducts Affected
• RELISTOR SUBCUTANEOUS* SOLUTION 8 MG/0.4ML
PA Criteria Criteria Details
Covered UsesOpioid-induced constipation (OIC) in adults with chronic non-cancer pain, OIC in adults with advanced illness
Exclusion Criteria
Required Medical Information
Patients with advanced illness who are receiving palliative care, for the treatment of opioid-induced constipation when response to laxative therapy has not been sufficient.
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 Months
Other Criteria
QL Criteria 0.4 ml Per 1 Day
Notes/References
Revision DatePrior Authorization: September 09, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
973
![Page 974: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/974.jpg)
RelpaxProducts Affected
• RELPAX
ST Criteria Documented step through TWO of the following: SUMATRIPTAN, NARATRIPTAN, RIZATRIPTAN
QL Criteria 6 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
974
![Page 975: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/975.jpg)
RemicadeProducts Affected
• REMICADE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
975
![Page 976: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/976.jpg)
RemodulinProducts Affected
• REMODULIN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST CriteriaRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/pulmonaryhypertensionagents.html
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
976
![Page 977: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/977.jpg)
Repaglinide-Metformin HClProducts Affected
• repaglinide-metformin hcl
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
977
![Page 978: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/978.jpg)
RepathaProducts Affected
• REPATHA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/PCSK9.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/PCSK9.html
QL Criteria 2 syringes Per 28 Days
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
978
![Page 979: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/979.jpg)
Repatha Pushtronex SystemProducts Affected
• REPATHA PUSHTRONEX SYSTEM
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/PCSK9.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/PCSK9.html
QL Criteria 1 syringe Per 1 month
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
979
![Page 980: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/980.jpg)
Repatha SureClickProducts Affected
• REPATHA SURECLICK
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/PCSK9.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/PCSK9.html
QL Criteria 2 syringes Per 28 Days
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
980
![Page 981: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/981.jpg)
RepronexProducts Affected
• REPRONEX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
981
![Page 982: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/982.jpg)
ResculaProducts Affected
• RESCULA
PA Criteria Criteria Details
Covered Uses Glaucoma
Exclusion Criteria
Required Medical Information
Documented step through latanoprost.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 bottle Per 1 month
Notes/References Annual Review: 03/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
982
![Page 983: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/983.jpg)
Reveal Blood Glucose TestProducts Affected
• REVEAL BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
983
![Page 984: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/984.jpg)
RevlimidProducts Affected
• REVLIMID
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
984
![Page 985: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/985.jpg)
Rexall Blood Glucose TestProducts Affected
• REXALL BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
985
![Page 986: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/986.jpg)
RexultiProducts Affected
• REXULTI
PA Criteria Criteria Details
Covered Uses Major Depressive Disorder (MDD), Schizophrenia
Exclusion Criteria
Required Medical Information
Documented diagnosis of Major Depressive Disorder (MDD) or Schizophrenia
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
ST Criteria Trial of two atypical generic antipsychotic medications (i.e. aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone)
QL Criteria 1 tablet Per 1 Day
Notes/References Annual Review: 08/2016
Revision DatePrior Authorization: December 02, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
986
![Page 987: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/987.jpg)
ReyatazProducts Affected
• REYATAZ ORAL CAPSULE 200 MG
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
987
![Page 988: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/988.jpg)
ReyatazProducts Affected
• REYATAZ ORAL CAPSULE 300 MG, 150 MG
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
988
![Page 989: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/989.jpg)
RiaSTAPProducts Affected
• RIASTAP
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
989
![Page 990: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/990.jpg)
Rightest GS100 Blood GlucoseProducts Affected
• RIGHTEST GS100 BLOOD GLUCOSE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
990
![Page 991: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/991.jpg)
Rightest GS300 Blood GlucoseProducts Affected
• RIGHTEST GS300 BLOOD GLUCOSE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
991
![Page 992: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/992.jpg)
Rightest GS550 Blood GlucoseProducts Affected
• RIGHTEST GS550 BLOOD GLUCOSE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
992
![Page 993: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/993.jpg)
Risedronate SodiumProducts Affected
• risedronate sodium oral tablet 5 mg, 30 mg, 35 mg
PA Criteria Criteria Details
Covered Uses Osteoporosis
Exclusion CriteriaNo failure of formulary bisphosphonates, use in combination with one or more bisphosphonates.
Required Medical Information
Documentation of a trial and failure of generic alendronate weekly (70mg weekly dose)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
993
![Page 994: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/994.jpg)
Risedronate SodiumProducts Affected
• risedronate sodium oral tablet delayed release
PA Criteria Criteria Details
Covered Uses Osteoporosis
Exclusion CriteriaNo failure of formulary bisphosphonates, use in combination with one or more bisphosphonates.
Required Medical Information
Documentation of a trial and failure of generic alendronate weekly (70mg weekly dose)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 4 tablet Per 1 month
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
994
![Page 995: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/995.jpg)
Risedronate SodiumProducts Affected
• risedronate sodium oral tablet 150 mg
PA Criteria Criteria Details
Covered Uses Osteoporosis
Exclusion CriteriaNo failure of formulary bisphosphonates, use in combination with one or more bisphosphonates.
Required Medical Information
Documentation of a trial and failure of generic alendronate weekly (70mg weekly dose)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 tablet Per 1 month
Notes/References Annual Review: 06/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
995
![Page 996: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/996.jpg)
RisperiDONEProducts Affected
• risperidone oral tablet dispersible 4 mg • risperidone oral tablet 4 mg
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
996
![Page 997: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/997.jpg)
RisperiDONEProducts Affected
• risperidone oral tablet 1 mg, 0.25 mg, 0.5 mg, 2 mg
• risperidone oral tablet dispersible 0.25 mg, 1 mg, 2 mg, 0.5 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
997
![Page 998: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/998.jpg)
RisperiDONEProducts Affected
• risperidone oral tablet 3 mg • risperidone oral tablet dispersible 3 mg
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
998
![Page 999: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/999.jpg)
RisperiDONE M-TABProducts Affected
• RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 2 MG, 1 MG
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
999
![Page 1000: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1000.jpg)
RisperiDONE M-TABProducts Affected
• RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 3 MG
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,000
![Page 1001: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1001.jpg)
RisperiDONE M-TABProducts Affected
• RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 4 MG
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,001
![Page 1002: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1002.jpg)
RituxanProducts Affected
• RITUXAN INTRAVENOUS* SOLUTION
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST CriteriaRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,002
![Page 1003: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1003.jpg)
RivastigmineProducts Affected
• rivastigmine
QL Criteria 1 patch Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,003
![Page 1004: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1004.jpg)
Rizatriptan BenzoateProducts Affected
• rizatriptan benzoate
QL Criteria 12 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,004
![Page 1005: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1005.jpg)
ROPINIRole HCl ERProducts Affected
• ropinirole hcl er oral tablet extended release 24 hr* 6 mg, 8 mg, 4 mg, 2 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,005
![Page 1006: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1006.jpg)
ROPINIRole HCl ERProducts Affected
• ropinirole hcl er oral tablet extended release 24 hr* 12 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,006
![Page 1007: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1007.jpg)
Rosuvastatin CalciumProducts Affected
• rosuvastatin calcium
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,007
![Page 1008: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1008.jpg)
RozeremProducts Affected
• ROZEREM
PA Criteria Criteria Details
Covered Uses Insomnia
Exclusion Criteria
Required Medical Information
Step through either zolpidem tartrate or zalelpon, and through zolpidem tartrate extended-release
Age Restrictions 18 years of age or older
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,008
![Page 1009: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1009.jpg)
SabrilProducts Affected
• SABRIL
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/anticonvulasants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,009
![Page 1010: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1010.jpg)
SabrilProducts Affected
• SABRIL
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/anticonvulasants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 6 packets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,010
![Page 1011: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1011.jpg)
SafyralProducts Affected
• SAFYRAL
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,011
![Page 1012: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1012.jpg)
SamscaProducts Affected
• SAMSCA ORAL TABLET 30 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/samsca.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,012
![Page 1013: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1013.jpg)
SamscaProducts Affected
• SAMSCA ORAL TABLET 15 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/samsca.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,013
![Page 1014: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1014.jpg)
SancusoProducts Affected
• SANCUSO
PA Criteria Criteria Details
Covered Uses Chemotherapy induced nausea and vomiting
Exclusion CriteriaCancer patients with non-chemotherapy related nausea and vomiting, patients with radiation-induced nausea and vomiting, patients with pregnancy-related nausea and vomiting, patients with post-operative nausea and vomiting
Required Medical Information
Patient is currently receiving chemotherapy and remains symptomatic despite treatment with oral ondansetron (Zofran) or oral granisetron (Kytril) or have documented inability to take oral antiemetics, including ODT formulations.
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 months
Other Criteria
QL Criteria 1 patch Per 1 month
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,014
![Page 1015: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1015.jpg)
SaphrisProducts Affected
• SAPHRIS
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
QL Criteria 2 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,015
![Page 1016: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1016.jpg)
SaphrisProducts Affected
• SAPHRIS
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,016
![Page 1017: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1017.jpg)
SavellaProducts Affected
• SAVELLA
PA Criteria Criteria Details
Covered Uses Fibromyalgia
Exclusion CriteriaPeripheral Neuropathy(s) (other than diabetic), General Anxiety Disorder or Panic Disorder, Post-operative pain
Required Medical Information
Documentation of trials of non-pharmacologic therapies (cognitive behavioral therapies, exercise etc.), and trial and failure of three (3) medications from the following drugs/drug classes: one tricyclic antidepressant (eg: amitriptyline), one muscle relaxant (eg: cyclobenzaprine), one SSRI, one SNRI, gabapentin, and tramadol
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References Annual Review: 03/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,017
![Page 1018: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1018.jpg)
Savella Titration PackProducts Affected
• SAVELLA TITRATION PACK
PA Criteria Criteria Details
Covered Uses Fibromyalgia
Exclusion CriteriaPeripheral Neuropathy(s) (other than diabetic), General Anxiety Disorder or Panic Disorder, Post-operative pain
Required Medical Information
Documentation of trials of non-pharmacologic therapies (cognitive behavioral therapies, exercise etc.), and trial and failure of three (3) medications from the following drugs/drug classes: one tricyclic antidepressant (eg: amitriptyline), one muscle relaxant (eg: cyclobenzaprine), one SSRI, one SNRI, gabapentin, and tramadol
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References Annual Review: 03/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,018
![Page 1019: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1019.jpg)
SeasoniqueProducts Affected
• SEASONIQUE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,019
![Page 1020: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1020.jpg)
SelzentryProducts Affected
• SELZENTRY
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,020
![Page 1021: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1021.jpg)
SensiparProducts Affected
• SENSIPAR
ST Criteria Documented step through CALCITRIOL (covered without trials for hyperparathyroidism and parathyroid carcinoma)
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,021
![Page 1022: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1022.jpg)
Serevent DiskusProducts Affected
• SEREVENT DISKUS
QL Criteria 2 blisters Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,022
![Page 1023: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1023.jpg)
SEROquel XRProducts Affected
• SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG
PA Criteria Criteria Details
Covered Uses Major depressive disorder (MDD), Bipolar disorder or schizophrenia
Exclusion Criteria
Required Medical Information
Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: May 23, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,023
![Page 1024: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1024.jpg)
SEROquel XRProducts Affected
• SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 300 MG, 400 MG, 50 MG
PA Criteria Criteria Details
Covered Uses Major depressive disorder (MDD), Bipolar disorder or schizophrenia
Exclusion Criteria
Required Medical Information
Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 23, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,024
![Page 1025: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1025.jpg)
Sertraline HClProducts Affected
• sertraline hcl oral tablet 25 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,025
![Page 1026: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1026.jpg)
Sertraline HClProducts Affected
• sertraline hcl oral concentrate
QL Criteria 10 ml Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,026
![Page 1027: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1027.jpg)
Sertraline HClProducts Affected
• sertraline hcl oral tablet 50 mg
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,027
![Page 1028: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1028.jpg)
Sertraline HClProducts Affected
• sertraline hcl oral tablet 100 mg
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,028
![Page 1029: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1029.jpg)
SharobelProducts Affected
• SHAROBEL
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,029
![Page 1030: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1030.jpg)
Sildenafil CitrateProducts Affected
• sildenafil citrate oral
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,030
![Page 1031: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1031.jpg)
SimcorProducts Affected
• SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR* 500-40 MG, 1000-40 MG
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,031
![Page 1032: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1032.jpg)
SimcorProducts Affected
• SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR* 750-20 MG, 500-20 MG, 1000-20 MG
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,032
![Page 1033: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1033.jpg)
SimponiProducts Affected
• SIMPONI SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Simponi.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 syringe Per 1 month
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,033
![Page 1034: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1034.jpg)
Simponi AriaProducts Affected
• SIMPONI ARIA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Simponi_Aria.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 vial Per 1 month
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,034
![Page 1035: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1035.jpg)
SimulectProducts Affected
• SIMULECT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/Simulect.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: March 07, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,035
![Page 1036: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1036.jpg)
SimvastatinProducts Affected
• simvastatin oral
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,036
![Page 1037: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1037.jpg)
Smartest Blood Glucose TestProducts Affected
• SMARTEST BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,037
![Page 1038: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1038.jpg)
Smartest EjectProducts Affected
• SMARTEST EJECT
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,038
![Page 1039: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1039.jpg)
Smartest ProtegeProducts Affected
• SMARTEST PROTEGE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,039
![Page 1040: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1040.jpg)
Sodium PhenylbutyrateProducts Affected
• sodium phenylbutyrate • sodium phenylbutyrate oral powder 3 gm/tsp
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 31, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,040
![Page 1041: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1041.jpg)
SoliaProducts Affected
• SOLIA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,041
![Page 1042: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1042.jpg)
Solus V2 TestProducts Affected
• SOLUS V2 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,042
![Page 1043: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1043.jpg)
Somatuline DepotProducts Affected
• SOMATULINE DEPOT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/Sandostatin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,043
![Page 1044: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1044.jpg)
SomavertProducts Affected
• SOMAVERT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,044
![Page 1045: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1045.jpg)
SovaldiProducts Affected
• SOVALDI
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 EA Per 1 Day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,045
![Page 1046: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1046.jpg)
Spiriva HandiHalerProducts Affected
• SPIRIVA HANDIHALER
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,046
![Page 1047: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1047.jpg)
Spiriva RespimatProducts Affected
• SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 1.25 MCG/ACT
QL Criteria 1 inhaler Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,047
![Page 1048: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1048.jpg)
SporanoxProducts Affected
• SPORANOX ORAL SOLUTION
PA Criteria Criteria Details
Covered UsesOnychomycosis, invasive fungal infection, uther fungal infection, superficial mycoses
Exclusion Criteria
Cosmetic use, patients with evidence of ventricular dysfunction such as CHF or a history of CHF. Coadministration with certain drugs metabolized by the cytochrome P-450 3A4 isoenzyme system (CYP3A4), cisapride, oral midazolam, pimozide, quinidine, dofetilide, triazolam, HMG-CoA reductase inhibitors metabolized by CYP3A4, such as lovastatin and simvastatin, and ergot alkaloids metabolized by CYP3A4, such as dihydroergotamine, ergotamine, ergonovine, and methylergonovine.
Required Medical Information
Itraconazole Capsules are covered for members who meet the following criteria: (1) Invasive fungal infections in patients who are immunocompromised, such as histoplamosis, aspergillosis, and blastomycosis, (2) Treatment of tinea barbae, tinea capitis, tinea favosa with previous treatment with terbinafine, (3) Treatment of tinea corporis, tinea cruris, tinea faciei, tinea manuum, tinea pedis with previous treatment with a topical antifungal and terbinafine, (4) Treatment of tinea versicolor with previous treatment with selenium sulfide and a topcial antifungal, (5) a diagnosis of majocchi granuloma, (6) Onychomycosis in diabetic patients or patients with peripheral vascular disease and either a positive onychomycosis susceptible pathogen culture or a positive PAS stain performed by a laboratory and documented trial/failure of terbinafine (generic Lamisil), or (7) Onychomycosis with documented disabling pain or impairment and a positive onychomycosis susceptible pathogen culture and documented step through terbinafine.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Nail: 12 wk(toe),5 wk (finger) per year,Invasive: 1-3 mo based on severity, Other Dx: 1-6 wk
Other Criteria
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,048
![Page 1049: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1049.jpg)
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,049
![Page 1050: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1050.jpg)
Sprintec 28Products Affected
• SPRINTEC 28
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,050
![Page 1051: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1051.jpg)
SprycelProducts Affected
• SPRYCEL ORAL TABLET 50 MG, 20 MG, 80 MG, 70 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,051
![Page 1052: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1052.jpg)
SprycelProducts Affected
• SPRYCEL ORAL TABLET 140 MG, 100 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,052
![Page 1053: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1053.jpg)
SronyxProducts Affected
• SRONYX
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,053
![Page 1054: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1054.jpg)
StavzorProducts Affected
• STAVZOR
PA Criteria Criteria Details
Covered Uses Epilepsy, Bipolar disorder, Prophylaxis of migraine headaches
Exclusion Criteria
Required Medical Information
FOR EPILEPSY OR BIPOLAR DISORDER: documentation of step through valproic acid capsules or divalproex sodium delayed release tablets. FOR PROPHYLAXIS OF MIGRAINE HEADACHES: documentation of step through 2 of the following: valproic acid capsules or divalproex sodium delayed release tablets, propranolol, or topiramate.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,054
![Page 1055: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1055.jpg)
StelaraProducts Affected
• STELARA INTRAVENOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Stelara.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 vials Per 30 Days
Notes/References
Revision DatePrior Authorization: November 08, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,055
![Page 1056: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1056.jpg)
StelaraProducts Affected
• STELARA SUBCUTANEOUS*
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 syringe Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,056
![Page 1057: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1057.jpg)
StimateProducts Affected
• STIMATE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/miscendocrine.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: February 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,057
![Page 1058: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1058.jpg)
Stiolto RespimatProducts Affected
• STIOLTO RESPIMAT
QL Criteria 1 inhaler Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,058
![Page 1059: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1059.jpg)
StivargaProducts Affected
• STIVARGA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,059
![Page 1060: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1060.jpg)
StratteraProducts Affected
• STRATTERA
ST Criteria Documented step through a STIMULANT
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,060
![Page 1061: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1061.jpg)
StriantProducts Affected
• STRIANT
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 2 buccal systems Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,061
![Page 1062: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1062.jpg)
StribildProducts Affected
• STRIBILD
PA Criteria Criteria Details
Covered Uses
A documented diagnosis of human immunodeficiency virus (HIV), AND a documented viral load assay AND CD4 count indicating that the patient is stable on Stribild (stable or increase in CD4 counts AND viral load less than 50 copies/ml)(FOR renewals/continuations ONLY). For treatment naïve patients only, a documented resistance test within the past 3 months demonstrating virologic susceptibility to all of the following components of Stribild: elvitegravir, emtricitabine, and tenofovir AND a documented contraindication or intolerance or allergy or failure of an adequate trial of one month of one of the preferred regimens: Triumeq (dolutegravir/abacavir/lamivudine) OR Tivicay (dolutegravir) plus Truvada (tenofovir disoproxil fumarate/emtricitabine) OR Isentress (Raltegravir) plus Truvada (tenofovir disoproxil fumarate/emtricitabine) OR Prezista (Darunavir) plus Norvir (ritonavir) plus Truvada (tenofovir disoproxil fumarate/emtricitabine)
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: September 11, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,062
![Page 1063: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1063.jpg)
SuboxoneProducts Affected
• SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG, 2-0.5 MG
PA Criteria Criteria Details
Covered UsesOpioid Dependence. NOTE: Prior Authorization does not apply to members residing in Massachusetts.
Exclusion Criteria
Medical literature does not support the concurrent use of opioids/Tramadol as part of opioid drug dependence treatment. Abstinence of opioids/Tramadol is required both during and following therapy with Suboxone/Subutex/Zubsolv/Bunavail/buprenorphine, and will only be covered when determined to be medically necessary (defined as short-term use during and following opioid dependence treatment for the treatment of acute pain related to surgery, dental procedure, or an emergency situation or for long-term use following opioid dependence treatment for the treatment of chronic pain. For long term use, the member must be treated by a single provider of their choice, opioids will only be covered when prescribed by this single provider, and this single provider is aware of past buprenorphine use for opioid dependence treatment in which an opioid dependence diagnosis). Physicians can contact (855) 746-0013 with any information related to the medical necessity for opioid/Tramadol therapy.
Required Medical Information
Prescriber provides verbal verification of patient's current and ongoing enrollment in an outpatient drug addiction treatment program/ counseling. If the member is currently enrolled, the approval will be 6 months. If the member is NOT enrolled (answer=no) and prescriber provides verbal verification of patient's agreed commitment to become enrolled in an acceptable drug addiction treatment program counseling, the approval will be for 2 months (Note: 1 time approval ONLY). If after 2 months member does not enroll in a program, then all future requests will be denied until member enrolls in a program.
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 months = current enrollement
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,063
![Page 1064: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1064.jpg)
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, the following conditions must be met: FOR BUPRENORPHONE SL: Member is pregnant or breastfeeding (Up to 120 tablets in 30 days)or member has a documented contraindication, intolerance, or allergy to buprenorphine-naloxone sublingual tablet or Suboxone (will allow up to 90 tablets per month for max length of approval of 6 months). FOR SUBOXONE OR BUPRENORPHINE-NALOXONE SUBLINGUAL TABLET 2mg/0.5mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 12 mg/daily for total of 42 tablets/films in 7 days). FOR ZUBSOLBV 1.4mg/0.36mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 8.4 mg/daily for total of 42 tablets/films in 7 days). Note: Aetna considers the following as acceptable programs: Outpatient drug addiction treatment programs and/or counseling, 12- step programs focused on "drug" addiction such as Narcotics Anonymous (N.A.), Other accepted programs can be found at http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx. Aetna considers the following as non-acceptable programs: On-line programs such as Here to Help, 12-step programs that are not focused on "drug" addiction (ex: Alcoholics Anonymous).
QL Criteria 3 films Per 1 day
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,064
![Page 1065: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1065.jpg)
SuboxoneProducts Affected
• SUBOXONE SUBLINGUAL FILM 12-3 MG
PA Criteria Criteria Details
Covered UsesOpioid Dependence. NOTE: Prior Authorization does not apply to members residing in Massachusetts.
Exclusion Criteria
Medical literature does not support the concurrent use of opioids/Tramadol as part of opioid drug dependence treatment. Abstinence of opioids/Tramadol is required both during and following therapy with Suboxone/Subutex/Zubsolv/Bunavail/buprenorphine, and will only be covered when determined to be medically necessary (defined as short-term use during and following opioid dependence treatment for the treatment of acute pain related to surgery, dental procedure, or an emergency situation or for long-term use following opioid dependence treatment for the treatment of chronic pain. For long term use, the member must be treated by a single provider of their choice, opioids will only be covered when prescribed by this single provider, and this single provider is aware of past buprenorphine use for opioid dependence treatment in which an opioid dependence diagnosis). Physicians can contact (855) 746-0013 with any information related to the medical necessity for opioid/Tramadol therapy.
Required Medical Information
Prescriber provides verbal verification of patient's current and ongoing enrollment in an outpatient drug addiction treatment program/ counseling. If the member is currently enrolled, the approval will be 6 months. If the member is NOT enrolled (answer=no) and prescriber provides verbal verification of patient's agreed commitment to become enrolled in an acceptable drug addiction treatment program counseling, the approval will be for 2 months (Note: 1 time approval ONLY). If after 2 months member does not enroll in a program, then all future requests will be denied until member enrolls in a program.
Age Restrictions
Prescriber Restrictions
Coverage Duration
6 months = current enrollement
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,065
![Page 1066: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1066.jpg)
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, the following conditions must be met: FOR BUPRENORPHONE SL: Member is pregnant or breastfeeding (Up to 120 tablets in 30 days)or member has a documented contraindication, intolerance, or allergy to buprenorphine-naloxone sublingual tablet or Suboxone (will allow up to 90 tablets per month for max length of approval of 6 months). FOR SUBOXONE OR BUPRENORPHINE-NALOXONE SUBLINGUAL TABLET 2mg/0.5mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 12 mg/daily for total of 42 tablets/films in 7 days). FOR ZUBSOLBV 1.4mg/0.36mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 8.4 mg/daily for total of 42 tablets/films in 7 days). Note: Aetna considers the following as acceptable programs: Outpatient drug addiction treatment programs and/or counseling, 12- step programs focused on "drug" addiction such as Narcotics Anonymous (N.A.), Other accepted programs can be found at http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx. Aetna considers the following as non-acceptable programs: On-line programs such as Here to Help, 12-step programs that are not focused on "drug" addiction (ex: Alcoholics Anonymous).
QL Criteria 2 films Per 1 day
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,066
![Page 1067: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1067.jpg)
SulfaSALAzineProducts Affected
• sulfasalazine oral
QL Criteria 8 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,067
![Page 1068: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1068.jpg)
SulfazineProducts Affected
• SULFAZINE
QL Criteria 8 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,068
![Page 1069: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1069.jpg)
Sulfazine ECProducts Affected
• SULFAZINE EC
QL Criteria 8 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,069
![Page 1070: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1070.jpg)
SUMAtriptanProducts Affected
• sumatriptan nasal
QL Criteria 3 nasal sprays Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,070
![Page 1071: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1071.jpg)
SUMAtriptan SuccinateProducts Affected
• sumatriptan succinate subcutaneous* solution6 mg/0.5ml
QL Criteria 10 vials Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,071
![Page 1072: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1072.jpg)
SUMAtriptan SuccinateProducts Affected
• sumatriptan succinate subcutaneous* 6 mg/0.5ml, 4 mg/0.5ml
• sumatriptan succinate subcutaneous* solution4 mg/0.5ml
QL Criteria 2 boxes (4 doses) Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,072
![Page 1073: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1073.jpg)
SUMAtriptan SuccinateProducts Affected
• sumatriptan succinate oral
QL Criteria 9 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,073
![Page 1074: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1074.jpg)
SUMAtriptan Succinate RefillProducts Affected
• sumatriptan succinate refill subcutaneous*
QL Criteria 2 boxes (4 doses) Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,074
![Page 1075: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1075.jpg)
Supprelin LAProducts Affected
• SUPPRELIN LA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,075
![Page 1076: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1076.jpg)
Sure Edge Glucose MonitorProducts Affected
• SURE EDGE GLUCOSE MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,076
![Page 1077: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1077.jpg)
Sure Edge TestProducts Affected
• SURE EDGE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,077
![Page 1078: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1078.jpg)
SureChek Blood Glucose MonitorProducts Affected
• SURECHEK BLOOD GLUCOSE MONITOR DEVICE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,078
![Page 1079: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1079.jpg)
SureChek Blood Glucose TestProducts Affected
• SURECHEK BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,079
![Page 1080: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1080.jpg)
SureStep Pro LinearityProducts Affected
• SURESTEP PRO LINEARITY
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,080
![Page 1081: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1081.jpg)
SureStep Pro TestProducts Affected
• SURESTEP PRO TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,081
![Page 1082: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1082.jpg)
Sure-Test EasyPlus Mini MeterProducts Affected
• SURE-TEST EASYPLUS MINI METER
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,082
![Page 1083: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1083.jpg)
Sure-Test EasyPlus Mini TestProducts Affected
• SURE-TEST EASYPLUS MINI TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,083
![Page 1084: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1084.jpg)
SutentProducts Affected
• SUTENT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,084
![Page 1085: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1085.jpg)
SyedaProducts Affected
• SYEDA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,085
![Page 1086: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1086.jpg)
SylatronProducts Affected
• SYLATRON SUBCUTANEOUS* KIT 300 MCG, 600 MCG, 4 X 300 MCG, 200 MCG, 4 X 200 MCG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,086
![Page 1087: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1087.jpg)
SymbicortProducts Affected
• SYMBICORT
ST Criteria Documented step through DULERA (covered without trials for COPD)
QL Criteria 1 inhaler Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,087
![Page 1088: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1088.jpg)
SymlinPen 120Products Affected
• SYMLINPEN 120 SUBCUTANEOUS*
PA Criteria Criteria Details
Covered Uses Type 1 and Type 2 diabetes
Exclusion Criteria
Required Medical Information
FOR TYPE 1 DIABETES: Patient must be using both basal insulin and short-acting insulin, and require three or more insulin injections daily, or using an insulin pump. FOR TYPE 2 DIABETES: Patient is receiving maximum tolerated doses of metformin, unless the patient is not a candidate for metformin therapy, and is using both basal insulin and short-acting insulin, and requires three or more insulin injections daily or is using an insulin pump, and failure to achieve adequate glycemic control despite individualized insulin management, defined as an A1C level is greater than 7% and less than 9%, and marked day-to-day variability in glucose levels (based on review of self-monitoring blood glucose levels), and home blood glucose monitoring is carried out three or more times per day, and is currently receiving individualized medical nutrition therapy by a registered dietician (requiring total daily carbohydrate intake monitoring), and is currently receiving ongoing care under the guidance of a healthcare professional skilled in the use of insulin and supported by the services of diabetes educators.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
Discontinuation Criteria includes recurrent unexplained hypoglycemia that requires medical assistance, persistent clinically significant nausea or associated abdominal pain, noncompliance with self-monitoring of blood glucose concentrations, noncompliance with insulin dose adjustments, or non compliance with scheduled health care professional contacts or recommended clinic visits
QL Criteria 4 bottles Per 1 month
Notes/References Annual Review: 05/2016
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,088
![Page 1089: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1089.jpg)
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,089
![Page 1090: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1090.jpg)
SymlinPen 60Products Affected
• SYMLINPEN 60 SUBCUTANEOUS*
PA Criteria Criteria Details
Covered Uses Type 1 and Type 2 diabetes
Exclusion Criteria
Required Medical Information
FOR TYPE 1 DIABETES: Patient must be using both basal insulin and short-acting insulin, and require three or more insulin injections daily, or using an insulin pump. FOR TYPE 2 DIABETES: Patient is receiving maximum tolerated doses of metformin, unless the patient is not a candidate for metformin therapy, and is using both basal insulin and short-acting insulin, and requires three or more insulin injections daily or is using an insulin pump, and failure to achieve adequate glycemic control despite individualized insulin management, defined as an A1C level is greater than 7% and less than 9%, and marked day-to-day variability in glucose levels (based on review of self-monitoring blood glucose levels), and home blood glucose monitoring is carried out three or more times per day, and is currently receiving individualized medical nutrition therapy by a registered dietician (requiring total daily carbohydrate intake monitoring), and is currently receiving ongoing care under the guidance of a healthcare professional skilled in the use of insulin and supported by the services of diabetes educators.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
Discontinuation Criteria includes recurrent unexplained hypoglycemia that requires medical assistance, persistent clinically significant nausea or associated abdominal pain, noncompliance with self-monitoring of blood glucose concentrations, noncompliance with insulin dose adjustments, or non compliance with scheduled health care professional contacts or recommended clinic visits
QL Criteria 4 pens Per 1 fill
Notes/References Annual Review: 05/2016
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,090
![Page 1091: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1091.jpg)
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,091
![Page 1092: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1092.jpg)
SynagisProducts Affected
• SYNAGIS
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Synagis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,092
![Page 1093: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1093.jpg)
SynriboProducts Affected
• SYNRIBO
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,093
![Page 1094: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1094.jpg)
TaclonexProducts Affected
• TACLONEX EXTERNAL SUSPENSION
ST Criteria Documented step through CALCIPOTRIENE AND MEDIUM TO HIGH POTENCY TOPICAL STEROID
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,094
![Page 1095: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1095.jpg)
Take ActionProducts Affected
• TAKE ACTION
QL Criteria 1 tablet Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,095
![Page 1096: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1096.jpg)
TamifluProducts Affected
• TAMIFLU ORAL CAPSULE
QL Criteria 20 capsules Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,096
![Page 1097: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1097.jpg)
TamifluProducts Affected
• TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML
QL Criteria 1 bottle Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,097
![Page 1098: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1098.jpg)
TarcevaProducts Affected
• TARCEVA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,098
![Page 1099: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1099.jpg)
TargretinProducts Affected
• TARGRETIN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,099
![Page 1100: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1100.jpg)
TasignaProducts Affected
• TASIGNA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,100
![Page 1101: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1101.jpg)
TaytullaProducts Affected
• TAYTULLA
QL Criteria 1.5 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,101
![Page 1102: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1102.jpg)
TazoracProducts Affected
• TAZORAC
ST Criteria Documented step through TRETINOIN
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,102
![Page 1103: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1103.jpg)
Taztia XTProducts Affected
• TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,103
![Page 1104: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1104.jpg)
Taztia XTProducts Affected
• TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 360 MG, 180 MG, 120 MG
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,104
![Page 1105: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1105.jpg)
TechnivieProducts Affected
• TECHNIVIE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,105
![Page 1106: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1106.jpg)
TekturnaProducts Affected
• TEKTURNA
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,106
![Page 1107: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1107.jpg)
Tekturna HCTProducts Affected
• TEKTURNA HCT
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,107
![Page 1108: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1108.jpg)
Telcare Blood Glucose TestProducts Affected
• TELCARE BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,108
![Page 1109: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1109.jpg)
TelmisartanProducts Affected
• telmisartan
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,109
![Page 1110: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1110.jpg)
Telmisartan-AmlodipineProducts Affected
• telmisartan-amlodipine
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,110
![Page 1111: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1111.jpg)
Telmisartan-HCTZProducts Affected
• telmisartan-hctz
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,111
![Page 1112: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1112.jpg)
TemazepamProducts Affected
• temazepam oral capsule 7.5 mg, 22.5 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,112
![Page 1113: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1113.jpg)
TemozolomideProducts Affected
• temozolomide
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,113
![Page 1114: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1114.jpg)
TestimProducts Affected
• TESTIM
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 2 10 gm packets Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,114
![Page 1115: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1115.jpg)
TestopelProducts Affected
• TESTOPEL
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,115
![Page 1116: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1116.jpg)
TestosteroneProducts Affected
• testosterone transdermal gel 50 mg/5gm (1%), 12.5 mg/act (1%)
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,116
![Page 1117: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1117.jpg)
TestosteroneProducts Affected
• testosterone transdermal gel 10 mg/act (2%)
PA Criteria Criteria Details
Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism
Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes
Required Medical Information
Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.
QL Criteria 4 pumps Per 1 day
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,117
![Page 1118: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1118.jpg)
Testosterone CypionateProducts Affected
• testosterone cypionate intramuscular* solution200 mg/ml
QL Criteria 10 vials Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,118
![Page 1119: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1119.jpg)
Testosterone CypionateProducts Affected
• testosterone cypionate intramuscular* solution100 mg/ml
QL Criteria 10 ml Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,119
![Page 1120: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1120.jpg)
TetrabenazineProducts Affected
• tetrabenazine oral tablet 12.5 mg
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/huntingtons_xenazine.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 8 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,120
![Page 1121: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1121.jpg)
TetrabenazineProducts Affected
• tetrabenazine oral tablet 25 mg
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/huntingtons_xenazine.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,121
![Page 1122: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1122.jpg)
Teveten HCTProducts Affected
• TEVETEN HCT ORAL TABLET 600-25 MG
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,122
![Page 1123: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1123.jpg)
TGT Blood Glucose TestProducts Affected
• tgt blood glucose test
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,123
![Page 1124: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1124.jpg)
ThalomidProducts Affected
• THALOMID
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,124
![Page 1125: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1125.jpg)
TiaGABine HClProducts Affected
• tiagabine hcl oral tablet 4 mg
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,125
![Page 1126: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1126.jpg)
TiaGABine HClProducts Affected
• tiagabine hcl oral tablet 2 mg
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,126
![Page 1127: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1127.jpg)
Tilia FeProducts Affected
• TILIA FE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,127
![Page 1128: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1128.jpg)
TirosintProducts Affected
• TIROSINT
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,128
![Page 1129: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1129.jpg)
TobramycinProducts Affected
• tobramycin inhalation
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/Aminoglycosides.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 10 ml Per 1 day
Notes/References
Revision DatePrior Authorization: February 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,129
![Page 1130: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1130.jpg)
Tolterodine TartrateProducts Affected
• tolterodine tartrate
ST Criteria Documented step through OXYBUTYNIN OR TROSPIUM IR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,130
![Page 1131: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1131.jpg)
Tolterodine Tartrate ERProducts Affected
• tolterodine tartrate er
ST Criteria Documented step through OXYBUTYNIN OR TROSPIUM IR
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,131
![Page 1132: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1132.jpg)
TopiramateProducts Affected
• topiramate oral capsule sprinkle
QL Criteria 4 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,132
![Page 1133: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1133.jpg)
ToviazProducts Affected
• TOVIAZ
ST Criteria Documented step through OXYBUTYNIN or TROSPIUM AND VESICARE or MYRBETRIQ
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,133
![Page 1134: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1134.jpg)
TracleerProducts Affected
• TRACLEER
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,134
![Page 1135: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1135.jpg)
TradjentaProducts Affected
• TRADJENTA
ST Criteria Documented step through METFORMIN 1500MG/day
QL Criteria 1 tablet Per 1 day
Notes/References Annual Review: 05/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,135
![Page 1136: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1136.jpg)
TraMADol HCl ERProducts Affected
• tramadol hcl er oral tablet extended release 24 hr*
ST Criteria Documented step through TRAMADOL
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,136
![Page 1137: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1137.jpg)
TraMADol HCl ER (Biphasic)Products Affected
• tramadol hcl er (biphasic)
ST Criteria Documented step through TRAMADOL
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,137
![Page 1138: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1138.jpg)
Tramadol-AcetaminophenProducts Affected
• tramadol-acetaminophen
QL Criteria 8 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,138
![Page 1139: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1139.jpg)
Tranexamic AcidProducts Affected
• tranexamic acid oral
QL Criteria 30 tablets Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,139
![Page 1140: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1140.jpg)
Travatan ZProducts Affected
• TRAVATAN Z
PA Criteria Criteria Details
Covered Uses Glaucoma
Exclusion Criteria
Required Medical Information
Documented step through latanoprost.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 bottle Per 1 month
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,140
![Page 1141: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1141.jpg)
TretinoinProducts Affected
• tretinoin external
QL Criteria 50 grams Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,141
![Page 1142: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1142.jpg)
Tretin-XProducts Affected
• TRETIN-X EXTERNAL CREAM 0.0375 %
ST Criteria Documented step through TRETINOIN
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,142
![Page 1143: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1143.jpg)
TrettenProducts Affected
• TRETTEN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,143
![Page 1144: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1144.jpg)
Triamcinolone AcetonideProducts Affected
• triamcinolone acetonide nasal aerosol†
ST Criteria Documented step through FLUTICASONE PROPIONATE AND FLUNISOLIDE
QL Criteria 1 bottle Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,144
![Page 1145: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1145.jpg)
TribenzorProducts Affected
• TRIBENZOR
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,145
![Page 1146: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1146.jpg)
Tri-Legest FeProducts Affected
• TRI-LEGEST FE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,146
![Page 1147: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1147.jpg)
Tri-LinyahProducts Affected
• TRI-LINYAH
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,147
![Page 1148: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1148.jpg)
TriNessa (28)Products Affected
• TRINESSA (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,148
![Page 1149: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1149.jpg)
Tri-Norinyl (28)Products Affected
• TRI-NORINYL (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,149
![Page 1150: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1150.jpg)
Tri-PrevifemProducts Affected
• TRI-PREVIFEM
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,150
![Page 1151: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1151.jpg)
Tri-SprintecProducts Affected
• TRI-SPRINTEC
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,151
![Page 1152: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1152.jpg)
Trivora (28)Products Affected
• TRIVORA (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,152
![Page 1153: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1153.jpg)
Trospium ChlorideProducts Affected
• trospium chloride
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,153
![Page 1154: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1154.jpg)
Trospium Chloride ERProducts Affected
• trospium chloride er
ST Criteria Documented step through OXYBUTYNIN OR TROSPIUM IR
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,154
![Page 1155: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1155.jpg)
TRUEtest TestProducts Affected
• TRUETEST TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,155
![Page 1156: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1156.jpg)
TrueTrack TestProducts Affected
• TRUETRACK TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,156
![Page 1157: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1157.jpg)
TruvadaProducts Affected
• TRUVADA
PA Criteria Criteria Details
Covered Uses HIV Infection, HIV Infection Pre-exposure Prophylaxis
Exclusion CriteriaTruvada is NOT covered for a use not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use. (see Off-Label Use Policy for determining accepted use)
Required Medical Information
Truvada is covered for members who have a documented diagnosis of human immunodeficiency virus (HIV) OR a documented diagnosis of initiating therapy for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 in adults at high risk AND documentation of a negative HIV antibody test taken immediately before starting Truvada for PrEP AND every 3 months thereafter while on therapy. Confirmation that creatinine clearance value greater than or equal to 60 mL/min before initiating Truvada for PrEP AND Serum creatinine and calculate creatinine clearance checks performed at 3 months after initiation and then every 6 months thereafter. NOTE: Members may receive a 30 days' supply of medication upon initial request of Truvada for PrEP diagnosis. After 30 days, above criteria must be met.
Age Restrictions
Prescriber Restrictions
Coverage Duration
HIV-1 infection: 3 years. Pre-exposure prophylaxis: 3 months.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 11, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,157
![Page 1158: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1158.jpg)
TruvadaProducts Affected
• TRUVADA
PA Criteria Criteria Details
Covered Uses
A documented diagnosis of human immunodeficiency virus (HIV) in a patient who weighs 17KG or more OR initiating therapy for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 in adults at high risk who have documentation of all of the following: A negative HIV antibody test taken immediately before starting Truvada for PrEP and every 3 months thereafter while on therapy, confirmation that creatinine clearance value is greater than or equal to 60 mL/min before initiating Truvada for PrEP, and serum creatinine and calculate creatinine clearance checks performed at 3 months after initiation and then every 6 months thereafter. NOTE: Members may receive a 30 days' supply of medication upon initial request of Truvada for PrEP diagnosis. After 30 days, above criteria must be met.
Exclusion Criteria
Required Medical Information
Age Restrictions none
Prescriber Restrictions
Coverage Duration
36 months HIV, 1 month initial PREP, 3 month PREP renewal
Other Criteria
4. Gilead Sciences, Inc.Truvada® (emtricitabine/tenofovir disoproxil fumarate) tablets, for oral use Foster City, CA: Gilead Sciences; 2004. Available at http://gilead.com/~/media/files/pdfs/medicines/hiv/truvada/truvada_pi.pdf Accessed June 9th,2016.
Notes/References
Revision DatePrior Authorization: July 07, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,158
![Page 1159: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1159.jpg)
Tudorza PressairProducts Affected
• TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT
QL Criteria 1 inhaler Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,159
![Page 1160: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1160.jpg)
TussiCapsProducts Affected
• TUSSICAPS
QL Criteria 20 capsules Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,160
![Page 1161: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1161.jpg)
TykerbProducts Affected
• TYKERB
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,161
![Page 1162: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1162.jpg)
TyzekaProducts Affected
• TYZEKA
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,162
![Page 1163: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1163.jpg)
UcerisProducts Affected
• UCERIS ORAL
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,163
![Page 1164: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1164.jpg)
UlesfiaProducts Affected
• ULESFIA
QL Criteria 3 bottles Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,164
![Page 1165: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1165.jpg)
UloricProducts Affected
• ULORIC
ST Criteria Documented step through ALLOPURINOL
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,165
![Page 1166: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1166.jpg)
Ultima TestProducts Affected
• ULTIMA TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,166
![Page 1167: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1167.jpg)
UltraTRAK ActiveProducts Affected
• ULTRATRAK ACTIVE
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,167
![Page 1168: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1168.jpg)
UltraTRAK PROProducts Affected
• ULTRATRAK PRO
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,168
![Page 1169: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1169.jpg)
UltraTRAK PRO TestProducts Affected
• ULTRATRAK PRO TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,169
![Page 1170: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1170.jpg)
UltraTRAK Ultimate MonitorProducts Affected
• ULTRATRAK ULTIMATE MONITOR
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,170
![Page 1171: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1171.jpg)
UltraTRAK Ultimate TestProducts Affected
• ULTRATRAK ULTIMATE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,171
![Page 1172: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1172.jpg)
UltresaProducts Affected
• ULTRESA
PA Criteria Criteria Details
Covered Uses Exocrine pancreatic Insufficiency
Exclusion CriteriaUses not approved by the FDA, uses unapproved and not supported by the literature or evidence as an accepted off-label use. (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Diagnosis of exocrine pancreatic insufficiency due to cystic fibrosis or other conditions and a documented trial of two weeks of Zenpep.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References Annual Review: 07/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,172
![Page 1173: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1173.jpg)
ValcyteProducts Affected
• VALCYTE
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/antiviraloraltopical.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,173
![Page 1174: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1174.jpg)
ValGANciclovir HClProducts Affected
• valganciclovir hcl
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/antiviraloraltopical.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,174
![Page 1175: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1175.jpg)
ValsartanProducts Affected
• valsartan
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,175
![Page 1176: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1176.jpg)
Valsartan-HydrochlorothiazideProducts Affected
• valsartan-hydrochlorothiazide
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,176
![Page 1177: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1177.jpg)
VectibixProducts Affected
• VECTIBIX INTRAVENOUS* SOLUTION 400 MG/20ML, 100 MG/5ML
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,177
![Page 1178: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1178.jpg)
VelcadeProducts Affected
• VELCADE INJECTION
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,178
![Page 1179: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1179.jpg)
VelivetProducts Affected
• VELIVET
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,179
![Page 1180: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1180.jpg)
Venlafaxine HClProducts Affected
• venlafaxine hcl oral tablet 50 mg
QL Criteria 6 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,180
![Page 1181: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1181.jpg)
Venlafaxine HClProducts Affected
• venlafaxine hcl oral tablet 100 mg, 25 mg
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,181
![Page 1182: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1182.jpg)
Venlafaxine HClProducts Affected
• venlafaxine hcl oral tablet 37.5 mg
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,182
![Page 1183: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1183.jpg)
Venlafaxine HClProducts Affected
• venlafaxine hcl oral tablet 75 mg
QL Criteria 5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,183
![Page 1184: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1184.jpg)
Venlafaxine HCl ERProducts Affected
• venlafaxine hcl er oral capsule extended release 24 hour 75 mg, 37.5 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,184
![Page 1185: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1185.jpg)
Venlafaxine HCl ERProducts Affected
• venlafaxine hcl er oral capsule extended release 24 hour 150 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,185
![Page 1186: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1186.jpg)
VeramystProducts Affected
• VERAMYST
ST Criteria Documented step through FLUTICASONE PROPIONATE AND FLUNISOLIDE
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,186
![Page 1187: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1187.jpg)
Verapamil HCl ERProducts Affected
• verapamil hcl er oral capsule extended release 24 hour 300 mg, 100 mg
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,187
![Page 1188: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1188.jpg)
Verapamil HCl ERProducts Affected
• verapamil hcl er oral capsule extended release 24 hour 200 mg
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,188
![Page 1189: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1189.jpg)
VESIcareProducts Affected
• VESICARE
ST Criteria Documented step through OXYBUTYNIN OR TROSPIUM IR
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,189
![Page 1190: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1190.jpg)
Victory AGM-4000 TestProducts Affected
• VICTORY AGM-4000 TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,190
![Page 1191: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1191.jpg)
Victory Blood Glucose SystemProducts Affected
• VICTORY BLOOD GLUCOSE SYSTEM
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,191
![Page 1192: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1192.jpg)
VictozaProducts Affected
• VICTOZA SUBCUTANEOUS*
PA Criteria Criteria Details
Covered Uses Type 2 Diabetes Mellitus (NIDDM)
Exclusion Criteria
Diagnosis of metabolic syndrome or any other pre-diabetic diagnosis, diagnosis of Type 1 Diabetes, treatment of diabetic ketoacidosis, pediatric patients, patients with multiple endocrine neoplasia syndrome type 2 (MEN2), family history of medullary thyroid carcinoma (MTC), patients with a history of pancreatitis
Required Medical Information
Patient must an A1C level is greater than 6.5%, have failed to obtain adequate glycemic control on maximum tolerated dose of metformin (unless the patient is not a candidate for metformin therapy) and a second antidiabetic agent (either a sulfonylurea, a thiazolidinedione (TZD), a DPP4-inhibitor or basal insulin)
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years
Other Criteria
QL Criteria 1 box-2 or 3 pens Per 1 month
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,192
![Page 1193: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1193.jpg)
VictrelisProducts Affected
• VICTRELIS
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 10 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,193
![Page 1194: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1194.jpg)
Viekira PakProducts Affected
• VIEKIRA PAK
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
QL Criteria 4 EA Per 1 Day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,194
![Page 1195: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1195.jpg)
Viekira XRProducts Affected
• VIEKIRA XR
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
QL Criteria 84 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,195
![Page 1196: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1196.jpg)
ViibrydProducts Affected
• VIIBRYD ORAL TABLET
PA Criteria Criteria Details
Covered Uses Major depressive disorder
Exclusion Criteria
Required Medical Information
Documentation of failure or unresponsiveness to THREE different antidepressants from at least two different therapeutic subclasses
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,196
![Page 1197: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1197.jpg)
ViibrydProducts Affected
• VIIBRYD ORAL KIT
PA Criteria Criteria Details
Covered Uses Major depressive disorder
Exclusion Criteria
Required Medical Information
Documentation of failure or unresponsiveness to THREE different antidepressants from at least two different therapeutic subclasses
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
Notes/References Annual Review: 05/2016
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,197
![Page 1198: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1198.jpg)
ViibrydProducts Affected
• VIIBRYD ORAL TABLET
PA Criteria Criteria Details
Covered Uses Major depressive disorder
Exclusion Criteria
Required Medical Information
Documentation of failure or unresponsiveness to THREE different antidepressants from at least two different therapeutic subclasses
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 1 tablet Per 1 day
Notes/References Annual Review: 05/2016
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,198
![Page 1199: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1199.jpg)
Viibryd Starter PackProducts Affected
• VIIBRYD STARTER PACK
PA Criteria Criteria Details
Covered Uses Major depressive disorder
Exclusion Criteria
Required Medical Information
Documentation of failure or unresponsiveness to THREE different antidepressants from at least two different therapeutic subclasses
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
Notes/References Annual Review: 05/2016
Revision DatePrior Authorization: October 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,199
![Page 1200: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1200.jpg)
VimpatProducts Affected
• VIMPAT ORAL TABLET
PA Criteria Criteria Details
Covered Uses partial-onset seizures
Exclusion Criteria
Required Medical Information
A documented diagnosis of partial-onset seizures and documentation of a trial and failure with one of the following agents: carbamazepine, divalproex dr/er/sprinkle, gabapentin, lamotrigine, levetiracetam/ER, oxcarbazepine, phenytoin, topiramate, valproic acid, or zonisamide.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: February 25, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,200
![Page 1201: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1201.jpg)
ViokaceProducts Affected
• VIOKACE
PA Criteria Criteria Details
Covered Uses Exocrine pancreatic Insufficiency
Exclusion CriteriaUses not approved by the FDA, uses unapproved and not supported by the literature or evidence as an accepted off-label use. (see Off-Label Use Policy for determining accepted use).
Required Medical Information
Diagnosis of exocrine pancreatic insufficiency due to cystic fibrosis or other conditions and a documented trial of two weeks of Zenpep.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,201
![Page 1202: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1202.jpg)
VioreleProducts Affected
• viorele
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,202
![Page 1203: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1203.jpg)
Viramune XRProducts Affected
• VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG
QL Criteria 3 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,203
![Page 1204: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1204.jpg)
VireadProducts Affected
• VIREAD ORAL TABLET
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,204
![Page 1205: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1205.jpg)
VistogardProducts Affected
• VISTOGARD
QL Criteria 20 packs Per 1 prescription
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,205
![Page 1206: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1206.jpg)
Vocal Point Blood Glucose TestProducts Affected
• VOCAL POINT BLOOD GLUCOSE TEST
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,206
![Page 1207: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1207.jpg)
VoriconazoleProducts Affected
• voriconazole oral tablet
PA Criteria Criteria Details
Covered Uses Fungal infections
Exclusion Criteria
Required Medical Information
Diagnosis of invasive aspergillosis or with a serious systemic fungal infection caused by Scedosporium apiospermum and Fusarium spp., for the treatment of esophageal candidiasis that is resistant to treatment with fluconazole and itraconazole, or for the treatment of candidemia in non-neutropenic patients and the following Candida infections: disseminated infections in skin and infections in abdomen, kidney, bladder wall, and wounds that are unresponsive to treatment with fluconazole (Continue therapy for 14 days after the patient is afebrile and blood cultures are negative).
Age Restrictions
Prescriber Restrictions
Coverage Duration
Invasive aspergillosis: 12 weeks, Oral Candidiasis: 3 weeks MAX, Candidemia: 12 weeks
Other Criteria
Notes/References
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,207
![Page 1208: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1208.jpg)
VotrientProducts Affected
• VOTRIENT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,208
![Page 1209: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1209.jpg)
VprivProducts Affected
• VPRIV
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,209
![Page 1210: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1210.jpg)
VytorinProducts Affected
• VYTORIN
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,210
![Page 1211: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1211.jpg)
VyvanseProducts Affected
• VYVANSE
PA Criteria Criteria Details
Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)
Exclusion Criteria
Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury
Required Medical Information
Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.
Age Restrictions 19 years and greater
Prescriber Restrictions
Coverage Duration
1 Year
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,211
![Page 1212: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1212.jpg)
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,212
![Page 1213: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1213.jpg)
WaveSense KeyNote Pro MeterProducts Affected
• WAVESENSE KEYNOTE PRO METER
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 1 meter Per 1 year
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,213
![Page 1214: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1214.jpg)
WaveSense PrestoProducts Affected
• WAVESENSE PRESTO
PA Criteria Criteria Details
Covered Uses Type II Diabetes Mellitus
Exclusion Criteria
Required Medical Information
There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 Years, limit one meter per year
Other Criteria
QL Criteria 300 strips Per 1 month
Notes/References
Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,214
![Page 1215: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1215.jpg)
WelcholProducts Affected
• WELCHOL ORAL PACKET
QL Criteria 1 pack Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,215
![Page 1216: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1216.jpg)
WeraProducts Affected
• WERA
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,216
![Page 1217: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1217.jpg)
Wide-Seal Diaphragm 60Products Affected
• WIDE-SEAL DIAPHRAGM 60
QL Criteria 1 diaphram Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,217
![Page 1218: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1218.jpg)
Wide-Seal Diaphragm 65Products Affected
• WIDE-SEAL DIAPHRAGM 65
QL Criteria 1 diaphram Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,218
![Page 1219: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1219.jpg)
Wide-Seal Diaphragm 70Products Affected
• WIDE-SEAL DIAPHRAGM 70
QL Criteria 1 diaphram Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,219
![Page 1220: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1220.jpg)
Wide-Seal Diaphragm 75Products Affected
• WIDE-SEAL DIAPHRAGM 75
QL Criteria 1 diaphram Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,220
![Page 1221: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1221.jpg)
Wide-Seal Diaphragm 80Products Affected
• WIDE-SEAL DIAPHRAGM 80
QL Criteria 1 diaphram Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,221
![Page 1222: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1222.jpg)
Wide-Seal Diaphragm 85Products Affected
• WIDE-SEAL DIAPHRAGM 85
QL Criteria 1 diaphram Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,222
![Page 1223: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1223.jpg)
Wide-Seal Diaphragm 90Products Affected
• WIDE-SEAL DIAPHRAGM 90
QL Criteria 1 diaphram Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,223
![Page 1224: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1224.jpg)
Wide-Seal Diaphragm 95Products Affected
• WIDE-SEAL DIAPHRAGM 95
QL Criteria 1 diaphram Per 1 year
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,224
![Page 1225: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1225.jpg)
WilateProducts Affected
• WILATE INTRAVENOUS* KIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,225
![Page 1226: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1226.jpg)
Wymzya FeProducts Affected
• WYMZYA FE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,226
![Page 1227: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1227.jpg)
XalkoriProducts Affected
• XALKORI
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,227
![Page 1228: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1228.jpg)
XeljanzProducts Affected
• XELJANZ
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Xeljanz_XeljanzXR.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Xeljanz_XeljanzXR.html
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,228
![Page 1229: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1229.jpg)
Xeljanz XRProducts Affected
• XELJANZ XR
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Xeljanz_XeljanzXR.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Xeljanz_XeljanzXR.html
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: November 01, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,229
![Page 1230: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1230.jpg)
XenazineProducts Affected
• XENAZINE ORAL TABLET 25 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/huntingtons_xenazine.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,230
![Page 1231: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1231.jpg)
XenazineProducts Affected
• XENAZINE ORAL TABLET 12.5 MG
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/huntingtons_xenazine.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 8 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,231
![Page 1232: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1232.jpg)
XeominProducts Affected
• XEOMIN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/botulinum_toxin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,232
![Page 1233: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1233.jpg)
XgevaProducts Affected
• XGEVA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,233
![Page 1234: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1234.jpg)
XiaflexProducts Affected
• XIAFLEX
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/dupuytrens_contracture_treatments.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,234
![Page 1235: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1235.jpg)
XifaxanProducts Affected
• XIFAXAN ORAL TABLET 550 MG
PA Criteria Criteria Details
Covered Uses Hepatic Encephalopathy, Irritable Bowel Syndrome (IBS) with Diarrhea.
Exclusion Criteria Pregnancy, Severe hepatic impairment (child-Pugh C)
Required Medical Information
FOR HEPATIC ENCHEPHALOPATHY: Member must have a documented diagnosis and be 18 years and older. FOR IBS WITH DIARRHEA: Member must have a documented diagnosis and must have been prescribed a 14-day course of therapy with three times a day dosing. For reauthorization of 2nd or 3rd course of therapy, there must be at least a 10-week treatment free period from the previous course of therapy.
Age Restrictions 18 years or older
Prescriber Restrictions
Coverage Duration
HEPATIC ENCEPHALOPATHY: 1 year. IBS: 14 days.
Other Criteria
QL Criteria 3 tablets Per 1 day
Notes/References Annual Review: 04/2016
Revision DatePrior Authorization: July 21, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,235
![Page 1236: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1236.jpg)
XifaxanProducts Affected
• XIFAXAN ORAL TABLET 200 MG
QL Criteria 9 tablets Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,236
![Page 1237: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1237.jpg)
XtandiProducts Affected
• XTANDI
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,237
![Page 1238: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1238.jpg)
XulaneProducts Affected
• XULANE
QL Criteria 1 box (3 patches) Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,238
![Page 1239: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1239.jpg)
XuridenProducts Affected
• XURIDEN
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 packets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 31, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,239
![Page 1240: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1240.jpg)
XynthaProducts Affected
• XYNTHA INTRAVENOUS* KIT 2000 UNIT, 1000 UNIT, 250 UNIT, 500 UNIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,240
![Page 1241: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1241.jpg)
Xyntha SolofuseProducts Affected
• XYNTHA SOLOFUSE INTRAVENOUS* KIT 3000 UNIT
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,241
![Page 1242: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1242.jpg)
XyremProducts Affected
• XYREM
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/cataplexy-xyrem.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: October 27, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,242
![Page 1243: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1243.jpg)
Yasmin 28Products Affected
• YASMIN 28
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,243
![Page 1244: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1244.jpg)
YAZProducts Affected
• YAZ
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,244
![Page 1245: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1245.jpg)
YervoyProducts Affected
• YERVOY
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,245
![Page 1246: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1246.jpg)
ZaleplonProducts Affected
• zaleplon
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,246
![Page 1247: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1247.jpg)
ZarahProducts Affected
• ZARAH
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,247
![Page 1248: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1248.jpg)
ZavescaProducts Affected
• ZAVESCA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 3 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,248
![Page 1249: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1249.jpg)
Zegerid OTCProducts Affected
• ZEGERID OTC
QL Criteria 1 capsule Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,249
![Page 1250: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1250.jpg)
ZelaparProducts Affected
• ZELAPAR
ST Criteria Documented step through SELEGILINE
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,250
![Page 1251: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1251.jpg)
ZelborafProducts Affected
• ZELBORAF
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 8 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,251
![Page 1252: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1252.jpg)
ZemairaProducts Affected
• ZEMAIRA
PA Criteria Criteria Details
Covered Uses pending
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
pending
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,252
![Page 1253: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1253.jpg)
ZenataneProducts Affected
• ZENATANE
ST Criteria Documented step through MINOCYCLINE OR DOXYCYCLINE
QL Criteria 2 capsules Per 1 day
Notes/References Annual Review: 02/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,253
![Page 1254: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1254.jpg)
ZenchentProducts Affected
• ZENCHENT
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,254
![Page 1255: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1255.jpg)
Zenchent FEProducts Affected
• ZENCHENT FE
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,255
![Page 1256: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1256.jpg)
ZepatierProducts Affected
• ZEPATIER
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,256
![Page 1257: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1257.jpg)
ZetiaProducts Affected
• ZETIA
ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,257
![Page 1258: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1258.jpg)
ZetonnaProducts Affected
• ZETONNA
ST Criteria Documented step through FLUTICASONE PROPIONATE AND FLUNISOLIDE
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,258
![Page 1259: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1259.jpg)
ZioptanProducts Affected
• ZIOPTAN
PA Criteria Criteria Details
Covered Uses Glaucoma
Exclusion Criteria
Required Medical Information
Documented step through latanoprost.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 years
Other Criteria
QL Criteria 1 box Per 1 fill
Notes/References Annual Review: 03/2016
Revision DatePrior Authorization: October 14, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,259
![Page 1260: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1260.jpg)
Ziprasidone HClProducts Affected
• ziprasidone hcl
QL Criteria 2 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,260
![Page 1261: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1261.jpg)
ZirganProducts Affected
• ZIRGAN
QL Criteria 5 grams Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,261
![Page 1262: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1262.jpg)
Zoledronic AcidProducts Affected
• zoledronic acid intravenous* concentrate • zoledronic acid intravenous* solution
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,262
![Page 1263: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1263.jpg)
ZolinzaProducts Affected
• ZOLINZA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 capsules Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,263
![Page 1264: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1264.jpg)
ZOLMitriptanProducts Affected
• zolmitriptan oral
ST Criteria Documented step through TWO of the following: SUMATRIPTAN, NARATRIPTAN, RIZATRIPTAN
QL Criteria 6 tablets Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,264
![Page 1265: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1265.jpg)
Zolpidem TartrateProducts Affected
• zolpidem tartrate oral
QL Criteria 2 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,265
![Page 1266: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1266.jpg)
Zolpidem Tartrate ERProducts Affected
• zolpidem tartrate er
QL Criteria 1 tablet Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,266
![Page 1267: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1267.jpg)
ZometaProducts Affected
• ZOMETA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,267
![Page 1268: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1268.jpg)
ZomigProducts Affected
• ZOMIG NASAL SOLUTION 5 MG
ST Criteria Documented step through TWO of the following: SUMATRIPTAN, NARATRIPTAN, RIZATRIPTAN
QL Criteria 1 box (6 doses) Per 1 month
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,268
![Page 1269: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1269.jpg)
Zovia 1/35E (28)Products Affected
• ZOVIA 1/35E (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,269
![Page 1270: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1270.jpg)
Zovia 1/50E (28)Products Affected
• ZOVIA 1/50E (28)
QL Criteria 1.5 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,270
![Page 1271: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1271.jpg)
ZoviraxProducts Affected
• ZOVIRAX EXTERNAL CREAM
ST Criteria Documented step through ORAL ACYCLOVIR
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,271
![Page 1272: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1272.jpg)
ZytigaProducts Affected
• ZYTIGA
PA Criteria Criteria Details
Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 day
Notes/References
Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,272
![Page 1273: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1273.jpg)
Index
Index
acamprosate calcium .................................................................................. 1ACCU-CHEK ACTIVE .......................................................................... 2ACCU-CHEK AVIVA IN VITRO STRIP ..................... 3ACCU-CHEK AVIVA PLUS IN VITRO ....................... 4ACCU-CHEK COMPACT PLUS ............................................. 5ACCU-CHEK COMPACT TEST DRUM ...................... 6ACCU-CHEK SMARTVIEW ........................................................ 7ACCUTREND GLUCOSE ................................................................. 8acitretin ........................................................................................................................ 9ACTEMRA INTRAVENOUS* ................................................ 10ACTIMMUNE ................................................................................................ 11ACTOPLUS MET XR .......................................................................... 12ACURA BLOOD GLUCOSE TEST .................................. 13ACUVAIL ............................................................................................................ 14adapalene external lotion .................................................................. 15ADCIRCA ............................................................................................................ 16adefovir dipivoxil ......................................................................................... 17ADVAIR DISKUS ..................................................................................... 18ADVAIR HFA ................................................................................................ 19ADVANCE INTUITION METER ........................................ 20ADVANCE INTUITION TEST ............................................... 21ADVATE ............................................................................................................... 22ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 1000-20 MG ............................................ 23ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 1000-40 MG, 500-20 MG ...... 25ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 750-20 MG ................................................ 24ADVOCATE BLOOD GLUCOSE MONITOR.............................................................................................................................................. 26ADVOCATE DUO DEVICE ....................................................... 27ADVOCATE REDI-CODE DEVICE ............................... 28ADVOCATE REDI-CODE IN VITRO .......................... 29ADVOCATE REDI-CODE+ ........................................................ 30ADVOCATE REDI-CODE+ TEST .................................... 31ADVOCATE TEST .................................................................................. 32adynovate ............................................................................................................... 33AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG ............................................................. 35AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG ............................................................. 34AFINITOR ........................................................................................................... 36AGAMATRIX AMP TEST ........................................................... 37AGAMATRIX JAZZ TEST .......................................................... 38AGAMATRIX KEYNOTE TEST ......................................... 39AGAMATRIX PRESTO PRO METER ......................... 40AGAMATRIX PRESTO TEST ................................................ 41AKYNZEO .......................................................................................................... 42ALDURAZYME .......................................................................................... 43
Index
alendronate sodium oral tablet 10 mg, 40 mg, 5 mg.............................................................................................................................................. 44alendronate sodium oral tablet 70 mg, 35 mg ......... 45alfuzosin hcl er ................................................................................................ 46ALIMTA ................................................................................................................. 47almotriptan malate ..................................................................................... 48alogliptin benzoate ..................................................................................... 49alogliptin-metformin hcl ..................................................................... 50alogliptin-pioglitazone .......................................................................... 51ALOXI INTRAVENOUS* SOLUTION 0.25 MG/5ML ................................................................................................................. 52ALPHANATE/VWF COMPLEX/HUMAN ............ 53ALPHANINE SD ........................................................................................ 54alprazolam er .................................................................................................... 55alprazolam xr .................................................................................................... 56ALPROLIX ......................................................................................................... 57ALTAVERA ...................................................................................................... 58ALTOPREV ....................................................................................................... 59ALVESCO ............................................................................................................ 60alyacen 1/35 ........................................................................................................ 61AMETHIA ............................................................................................................ 62AMETHIA LO ................................................................................................ 63AMETHYST ..................................................................................................... 64AMITIZA .............................................................................................................. 65amlodipine besylate-valsartan .................................................... 66AMNESTEEM ................................................................................................ 67amphetamine salt combo .................................................................... 68amphetamine-dextroamphet er ................................................... 69amphetamine-dextroamphetamine ......................................... 71AMPYRA .............................................................................................................. 72ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR ................................................................ 73ANDROGEL PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%) ................................................................................................ 78ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%) ..................................................................... 79ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%) ............................................................................. 75ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%) .......................................................................................... 76ANDROGEL TRANSDERMAL GEL 40.5 MG/2.5GM (1.62%) ................................................................................. 74ANDROGEL TRANSDERMAL GEL 50 MG/5GM (1%) ................................................................................................ 77ANZEMET ORAL ..................................................................................... 80APIDRA .................................................................................................................. 81APIDRA SOLOSTAR SUBCUTANEOUS* .......... 82APRI ............................................................................................................................. 83APRISO ................................................................................................................... 84
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,273
![Page 1274: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1274.jpg)
Index
ARALAST NP ................................................................................................ 85ARANELLE ....................................................................................................... 86ARANESP (ALBUMIN FREE) INJECTION ........ 87ARANESP (ALBUMIN FREE) INJECTION ........ 88ARANESP (ALBUMIN FREE) INJECTION SOLUTION 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 150 MCG/0.75ML, 10 MCG/0.4ML, 60 MCG/ML, 100 MCG/ML, 200 MCG/ML ................... 87ARCALYST ....................................................................................................... 89ARCAPTA NEOHALER .................................................................. 90aripiprazole oral solution .................................................................. 92aripiprazole oral tablet ........................................................................ 91aripiprazole oral tablet dispersible ...................................... 91armodafinil oral tablet 150 mg, 200 mg, 250 mg.............................................................................................................................................. 93armodafinil oral tablet 50 mg ...................................................... 95ARZERRA ........................................................................................................... 97ASCENSIA AUTODISC TEST ............................................... 98ASMANEX 120 METERED DOSES ............................... 99ASMANEX 14 METERED DOSES ............................... 100ASMANEX 30 METERED DOSES ............................... 101ASMANEX 60 METERED DOSES ............................... 102ASSURE 3 TEST ..................................................................................... 103ASSURE 4 METER ............................................................................. 104ASSURE 4 TEST ..................................................................................... 105ASSURE PLATINUM ...................................................................... 106ASSURE PLATINUM METER ........................................... 107ASSURE PRO BLOOD GLUCOSE METER .... 108ASSURE PRO TEST .......................................................................... 109atorvastatin calcium oral ............................................................... 110ATRIPLA ........................................................................................................... 111AUBAGIO ........................................................................................................ 112AVANDAMET ORAL TABLET 2-1000 MG........................................................................................................................................... 114AVANDAMET ORAL TABLET 2-500 MG ...... 113AVANDIA ....................................................................................................... 115AVIANE .............................................................................................................. 116AVITA EXTERNAL CREAM .............................................. 117AVONEX ........................................................................................................... 118AVONEX PEN INTRAMUSCULAR* ...................... 119AVONEX PREFILLED INTRAMUSCULAR*........................................................................................................................................... 120AXIRON ............................................................................................................. 121AZILECT ........................................................................................................... 122AZOR ...................................................................................................................... 123AZURETTE .................................................................................................... 124balsalazide disodium ............................................................................ 125BALZIVA ......................................................................................................... 126BANZEL ORAL SUSPENSION ......................................... 128BANZEL ORAL TABLET ......................................................... 127BARACLUDE ORAL TABLET ......................................... 129
Index
BAYER BREEZE 2 TEST .......................................................... 130BAYER CONTOUR MONITOR DEVICE ........... 131BAYER CONTOUR NEXT TEST ................................... 132BAYER CONTOUR TEST ........................................................ 133BEBULIN .......................................................................................................... 134BEBULIN VH ............................................................................................. 135BECONASE AQ ....................................................................................... 136BENICAR ......................................................................................................... 137BENICAR HCT ......................................................................................... 138BENLYSTA ................................................................................................... 139BETASERON SUBCUTANEOUS* KIT ................ 140bexarotene ......................................................................................................... 141BG STAR TEST ........................................................................................ 142bicalutamide ................................................................................................... 143bimatoprost ophthalmic ................................................................... 144BIVIGAM ......................................................................................................... 145BOSULIF ORAL TABLET 100 MG ............................. 146BOSULIF ORAL TABLET 500 MG ............................. 147BOTOX ................................................................................................................ 148BRAVELLE ................................................................................................... 149BREEZE 2 BLOOD GLUCOSE SYSTEM ........... 150BREVICON (28) ...................................................................................... 151briellyn ................................................................................................................... 152BRILINTA ....................................................................................................... 153BROVANA ..................................................................................................... 154budesonide inhalation ........................................................................ 155BUNAVAIL ................................................................................................... 156BUPHENYL ORAL TABLET ............................................... 158buprenorphine hcl sublingual tablet sublingual 2 mg ................................................................................................................................. 161buprenorphine hcl sublingual tablet sublingual 8 mg ................................................................................................................................. 159buprenorphine hcl-naloxone hcl ........................................... 163BUPROBAN .................................................................................................. 165bupropion hcl er (smoking det) .............................................. 167bupropion hcl er (sr) ............................................................................ 168bupropion hcl er (xl) ............................................................................ 169bupropion hcl oral .................................................................................. 166butorphanol tartrate nasal ........................................................... 170BUTRANS TRANSDERMAL PATCH WEEKLY 20 MCG/HR, 10 MCG/HR, 5 MCG/HR .................... 171BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED .............................................................................. 172BYETTA 10 MCG PEN SUBCUTANEOUS*........................................................................................................................................... 173BYETTA 5 MCG PEN SUBCUTANEOUS* ..... 174BYSTOLIC ORAL TABLET 2.5 MG, 5 MG, 10 MG .............................................................................................................................. 176BYSTOLIC ORAL TABLET 20 MG ........................... 175calcipotriene external ......................................................................... 177calcipotriene-betameth diprop ................................................ 178
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,274
![Page 1275: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1275.jpg)
Index
calcitonin (salmon) ................................................................................ 179CALCITRENE ............................................................................................ 180CAMILA ............................................................................................................. 181CAMRESE ....................................................................................................... 182CAMRESE LO ........................................................................................... 183CANASA ............................................................................................................ 184candesartan cilexetil oral tablet 4 mg, 8 mg, 16 mg........................................................................................................................................... 185candesartan cilexetil-hctz .............................................................. 186capecitabine .................................................................................................... 187CAPRELSA ORAL TABLET 100 MG ...................... 188CAPRELSA ORAL TABLET 300 MG ...................... 189CARBAGLU ................................................................................................. 190CARDURA XL .......................................................................................... 191CARESENS N GLUCOSE SYSTEM ........................... 192CARESENS N GLUCOSE TEST ...................................... 193CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 6 GM, 12 GM .................................. 194CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 300 MG, 180 MG........................................................................................................................................... 195CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG ............................................... 196CAYSTON ....................................................................................................... 197CAZIANT ......................................................................................................... 198cefixime ................................................................................................................. 199celecoxib oral ................................................................................................ 200CERDELGA ................................................................................................... 201CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT .............................................. 202CESAMET ....................................................................................................... 203CESIA .................................................................................................................... 204CETROTIDE SUBCUTANEOUS* KIT 0.25 MG........................................................................................................................................... 205cevimeline hcl ................................................................................................ 206CHANTIX ......................................................................................................... 207CHANTIX CONTINUING MONTH PAK ............ 208CHANTIX STARTING MONTH PAK ..................... 209CHATEAL ....................................................................................................... 210CHENODAL ................................................................................................. 211chorionic gonadotropin intramuscular* ..................... 212CIALIS ORAL TABLET 5 MG ........................................... 213CIMZIA PREFILLED ....................................................................... 215CIMZIA STARTER KIT ............................................................... 216CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG........................................................................................................................................... 214citalopram hydrobromide oral tablet 10 mg, 20 mg........................................................................................................................................... 217citalopram hydrobromide oral tablet 40 mg .......... 218CLARAVIS ..................................................................................................... 219CLEVER CHEK AUTO-CODE ........................................... 220
Index
CLEVER CHEK AUTO-CODE SYSTEM ............ 221CLEVER CHEK AUTO-CODE TEST ....................... 222CLEVER CHEK AUTO-CODE VOICE ................... 223CLEVER CHEK AUTO-CODE VOICE IN VITRO ................................................................................................................... 224CLEVER CHEK TEST .................................................................... 225CLEVER CHOICE AUTO-CODE SYSTEM ..... 226CLEVER CHOICE AUTO-CODE TEST ................ 227CLEVER CHOICE MICRO TEST ................................... 228CLEVER CHOICE MINI SYSTEM ............................... 229CLIMARA PRO ........................................................................................ 230clonidine hcl er ............................................................................................ 231clopidogrel bisulfate ............................................................................. 232clozapine oral tablet 100 mg ..................................................... 234clozapine oral tablet 200 mg ..................................................... 237clozapine oral tablet 50 mg, 25 mg ................................... 233clozapine oral tablet dispersible 100 mg ................... 234clozapine oral tablet dispersible 12.5 mg ................. 236clozapine oral tablet dispersible 150 mg, 200 mg........................................................................................................................................... 235clozapine oral tablet dispersible 25 mg ....................... 233COAGADEX ................................................................................................. 238colchicine oral tablet ........................................................................... 239COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 227.1 GM ....... 240COMBIPATCH .......................................................................................... 241COMETRIQ (100 MG DAILY DOSE) ...................... 242COMETRIQ (140 MG DAILY DOSE) ...................... 243COMETRIQ (60 MG DAILY DOSE) .......................... 244COMPLERA .................................................................................................. 245CONTROL AST ....................................................................................... 246CONTROL TEST .................................................................................... 247COPAXONE SUBCUTANEOUS* 20 MG/ML........................................................................................................................................... 249COPAXONE SUBCUTANEOUS* 40 MG/ML........................................................................................................................................... 248CORDRAN EXTERNAL TAPE ......................................... 250COREG CR ..................................................................................................... 251CORIFACT ..................................................................................................... 252COSOPT PF .................................................................................................... 253CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 6000 UNIT ................................................. 254CRINONE ......................................................................................................... 255CRYSELLE-28 ........................................................................................... 256CUVPOSA ....................................................................................................... 257CYCLAFEM 1/35 ................................................................................... 258CYCLESSA .................................................................................................... 259CYCLOSET .................................................................................................... 260DACOGEN ...................................................................................................... 261DAKLINZA .................................................................................................... 262
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,275
![Page 1276: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1276.jpg)
Index
DAKLINZA .................................................................................................... 263DALIRESP ....................................................................................................... 264darifenacin hydrobromide er ..................................................... 265DASETTA 1/35 ......................................................................................... 266DAYSEE ............................................................................................................. 267DAYTRANA ................................................................................................. 268DEBLITANE ................................................................................................. 270decitabine ........................................................................................................... 271DELZICOL ...................................................................................................... 272DENAVIR ......................................................................................................... 273DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 150 MG/ML ...................................................... 274DEPO-SUBQ PROVERA 104 SUBCUTANEOUS* SUSPENSION ............................. 275DESCOVY ....................................................................................................... 276desloratadine ................................................................................................. 277DESOGEN ....................................................................................................... 278DEXCOM G4 PLATINUM RECEIVER .................. 279DEXCOM G4 PLATINUM SENSOR KIT ........... 280DEXCOM G4 PLATINUM TRANSMITTER........................................................................................................................................... 281DEXCOM G4 SENSOR ................................................................. 282DEXILANT ..................................................................................................... 283dexmethylphenidate hcl .................................................................... 285dexmethylphenidate hcl er ............................................................ 286dextroamphetamine sulfate er .................................................. 290dextroamphetamine sulfate oral solution .................. 288dextroamphetamine sulfate oral tablet ......................... 289diazepam gel ................................................................................................... 291diclofenac sodium transdermal gel 1 % ...................... 292DIFICID ............................................................................................................... 293diltiazem cd oral capsule extended release 24 hour120 mg, 180 mg .......................................................................................... 295diltiazem cd oral capsule extended release 24 hour240 mg .................................................................................................................... 294diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 300 mg, 360 mg, 120 mg, 420 mg .................................................................................................................... 298diltiazem hcl er beads oral capsule extended release 24 hour 240 mg .................................................................... 299diltiazem hcl er coated beads oral capsule extended release 24 hour 240 mg ........................................ 301diltiazem hcl er coated beads oral capsule extended release 24 hour 300 mg, 180 mg, 120 mg, 360 mg .................................................................................................................... 300diltiazem hcl er oral capsule extended release 12 hour 120 mg .................................................................................................... 296diltiazem hcl er oral capsule extended release 24 hour 180 mg, 120 mg ........................................................................... 296diltiazem hcl er oral capsule extended release 24 hour 240 mg .................................................................................................... 297
Index
dilt-xr oral capsule extended release 24 hour 180 mg, 120 mg ....................................................................................................... 302dilt-xr oral capsule extended release 24 hour 240 mg ................................................................................................................................. 303DIPENTUM .................................................................................................... 304donepezil hcl oral tablet 10 mg .............................................. 306donepezil hcl oral tablet 23 mg .............................................. 305dronabinol ......................................................................................................... 307drospiren-eth estrad-levomefol ............................................... 308drospirenone-ethinyl estradiol oral tablet 3-0.03 mg ................................................................................................................................. 309DULERA ............................................................................................................ 310duloxetine hcl oral capsule delayed release particles 20 mg ............................................................................................ 313duloxetine hcl oral capsule delayed release particles 30 mg, 60 mg ...................................................................... 311duloxetine hcl oral capsule delayed release particles 40 mg ............................................................................................ 312dutasteride ......................................................................................................... 314easy plus ii glucose system ........................................................... 315easy plus ii glucose test .................................................................... 316EASY STEP GLUCOSE MONITOR DEVICE........................................................................................................................................... 317EASY STEP TEST ................................................................................ 318easy talk blood glucose system device ........................... 319easy talk blood glucose test ......................................................... 320EASY TOUCH TEST ........................................................................ 321easy trak blood glucose test ........................................................ 322EASYGLUCO IN VITRO ........................................................... 323EASYMAX 15 TEST ......................................................................... 324EASYMAX L BLOOD GLUCOSE DEVICE .... 325EASYMAX N BLOOD GLUCOSE DEVICE ... 326EASYMAX NG BLOOD GLUCOSE DEVICE........................................................................................................................................... 327EASYMAX TEST .................................................................................. 328EASYMAX V BLOOD GLUCOSE DEVICE ... 329EASYMAX V2 BLOOD GLUCOSE DEVICE........................................................................................................................................... 330easyplus blood glucose test .......................................................... 331EASYPRO PLUS IN VITRO ................................................... 332EDARBI .............................................................................................................. 333EDARBYCLOR ........................................................................................ 334EDURANT ....................................................................................................... 335EFFIENT ............................................................................................................ 336EGRIFTA SUBCUTANEOUS* SOLUTION RECONSTITUTED 2 MG ........................................................... 337ELAPRASE ..................................................................................................... 338ELELYSO ......................................................................................................... 339ELEMENT PLUS .................................................................................... 340ELEMENT TEST .................................................................................... 341ELIDEL ................................................................................................................ 342
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,276
![Page 1277: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1277.jpg)
Index
ELINEST ............................................................................................................ 343ELIQUIS ............................................................................................................. 344ELLA ....................................................................................................................... 345ELOCTATE .................................................................................................... 346EMBEDA ........................................................................................................... 347EMBRACE BLOOD GLUCOSE MONITOR ... 348EMBRACE BLOOD GLUCOSE TEST .................... 349EMEND ORAL CAPSULE 125 MG, 80 MG, 40 MG .............................................................................................................................. 351EMEND ORAL CAPSULE 80 & 125 MG ............ 350EMOQUETTE ............................................................................................. 352EMSAM ............................................................................................................... 353EMTRIVA ORAL CAPSULE ................................................ 354ENBREL SUBCUTANEOUS* 25 MG/0.5ML........................................................................................................................................... 356ENBREL SUBCUTANEOUS* 50 MG/ML ......... 355ENBREL SUBCUTANEOUS* KIT ............................... 355ENBREL SURECLICK SUBCUTANEOUS*........................................................................................................................................... 357ENDOMETRIN ......................................................................................... 358ENJUVIA ORAL TABLET 0.9 MG, 0.45 MG, 0.625 MG, 0.3 MG ................................................................................. 359ENJUVIA ORAL TABLET 1.25 MG ........................... 360enoxaparin sodium ................................................................................. 361ENPRESSE-28 ............................................................................................ 362entecavir oral tablet 1 mg ............................................................. 363EPCLUSA ......................................................................................................... 364EPIDUO ............................................................................................................... 365EPIDUO FORTE ...................................................................................... 366epinephrine injection 0.3 mg/0.3ml, 0.15 mg/0.15ml ........................................................................................................... 367EPIPEN 2-PAK INJECTION ................................................... 368EPOGEN INJECTION SOLUTION 3000 UNIT/ML, 20000 UNIT/ML, 4000 UNIT/ML, 10000 UNIT/ML, 2000 UNIT/ML .................................... 369epoprostenol sodium ............................................................................ 370eprosartan mesylate .............................................................................. 371ERIVEDGE ..................................................................................................... 372ERRIN .................................................................................................................... 373escitalopram oxalate oral tablet 10 mg ....................... 375escitalopram oxalate oral tablet 5 mg, 20 mg ..... 374esomeprazole magnesium .............................................................. 376estradiol transdermal patch biweekly ............................ 379estradiol transdermal patch weekly .................................. 378estradiol-norethindrone acet ..................................................... 380ESTROGEL .................................................................................................... 381ESTROSTEP FE ....................................................................................... 382eszopiclone ....................................................................................................... 383EVAMIST ......................................................................................................... 384EVENCARE + BLOOD GLUCOSE TEST .......... 385EVENCARE BLOOD GLUCOSE TEST ................ 386
Index
EVENCARE G2 MONITOR .................................................... 387EVENCARE G2 TEST .................................................................... 388EVENCARE G3 MONITOR .................................................... 389EVENCARE G3 TEST .................................................................... 390EVOLUTION AUTOCODE ..................................................... 392EVOLUTION AUTOCODE IN VITRO ................... 391EXJADE .............................................................................................................. 393EXTAVIA SUBCUTANEOUS* KIT ........................... 394EZ SMART BLOOD GLUCOSE TEST .................... 395EZ SMART MONITORING SYSTEM ...................... 396EZ SMART PLUS GLUCOSE TEST ........................... 397EZ SMART PLUS MONITORING SYS ................. 398FABRAZYME ............................................................................................ 399FALMINA ........................................................................................................ 400famciclovir oral tablet 125 mg, 250 mg ....................... 401famciclovir oral tablet 500 mg ................................................ 402FANAPT ............................................................................................................. 403FANAPT TITRATION PACK ............................................... 404felodipine er .................................................................................................... 405FEMCON FE ................................................................................................. 406FEMHRT LOW DOSE .................................................................... 407FEMRING ......................................................................................................... 408fenofibrate micronized ....................................................................... 411fenofibrate oral ........................................................................................... 409fenofibrate oral ........................................................................................... 410fenofibric acid oral tablet .............................................................. 412fentanyl .................................................................................................................. 413fentanyl .................................................................................................................. 414fentanyl citrate buccal ........................................................................ 415FERRIPROX ................................................................................................. 416FIFTY50 GLUCOSE TEST 2.0 ............................................ 417FIRAZYR .......................................................................................................... 418FIRST-PROGESTERONE VGS 100 ............................. 419FIRST-PROGESTERONE VGS 200 ............................. 420FIRST-PROGESTERONE VGS 25 ................................. 421FIRST-PROGESTERONE VGS 400 ............................. 422FIRST-PROGESTERONE VGS 50 ................................. 423FLEBOGAMMA DIF ........................................................................ 424FLOVENT DISKUS ............................................................................ 425FLOVENT HFA ........................................................................................ 426flunisolide nasal solution 25 mcg/act (0.025%)........................................................................................................................................... 427fluoxetine hcl oral capsule 10 mg ........................................ 433fluoxetine hcl oral capsule 20 mg ........................................ 431fluoxetine hcl oral capsule 40 mg ........................................ 432fluoxetine hcl oral capsule delayed release ............ 429fluoxetine hcl oral tablet 10 mg ............................................. 430fluoxetine hcl oral tablet 20 mg ............................................. 428fluvastatin sodium .................................................................................... 434fluvastatin sodium er ............................................................................ 435fluvoxamine maleate oral tablet 100 mg ..................... 437
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,277
![Page 1278: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1278.jpg)
Index
fluvoxamine maleate oral tablet 25 mg, 50 mg........................................................................................................................................... 436FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 35 MG, 25 MG .......................... 438FOLLISTIM AQ ....................................................................................... 440fondaparinux sodium ........................................................................... 441FORA D10 2-IN-1 MONITOR .............................................. 442FORA D10 BLOOD GLUCOSE TEST ...................... 443FORA D15G 2-IN-1 MONITOR ......................................... 444FORA D15G BLOOD GLUCOSE TEST ................ 445FORA D20 2-IN-1 MONITOR .............................................. 446FORA D20 BLOOD GLUCOSE TEST ...................... 447FORA G20 BLOOD GLUCOSE TEST ...................... 448FORA G30A BLOOD GLUCOSE SYSTEM ..... 449FORA G30A BLOOD GLUCOSE TEST ................ 450FORA GD20 BLOOD GLUCOSE SYSTEM ..... 451FORA GD20 TEST ............................................................................... 452FORA V10 BLOOD GLUCOSE SYSTEM .......... 453FORA V10 BLOOD GLUCOSE TEST ...................... 454FORA V12 BLOOD GLUCOSE SYSTEM .......... 455FORA V12 BLOOD GLUCOSE TEST ...................... 456FORA V20 BLOOD GLUCOSE SYSTEM .......... 457FORA V20 BLOOD GLUCOSE TEST ...................... 458FORA V30A BLOOD GLUCOSE SYSTEM DEVICE ............................................................................................................... 459FORA V30A BLOOD GLUCOSE TEST ................ 460FORACARE GD40 MONITOR ........................................... 461FORACARE GD40 TEST ........................................................... 462FORACARE PREMIUM V10 ................................................ 463FORACARE PREMIUM V10 TEST ............................. 464FORADIL AEROLIZER ............................................................... 465FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML ................................................................................................... 466FORTESTA ..................................................................................................... 467FORTICAL ...................................................................................................... 468FOSAMAX PLUS D ........................................................................... 469FRAGMIN SUBCUTANEOUS* SOLUTION 5000 UNIT/0.2ML, 18000 UNT/0.72ML, 12500 UNIT/0.5ML, 2500 UNIT/0.2ML, 10000 UNIT/ML, 15000 UNIT/0.6ML ............................................ 470FRAGMIN SUBCUTANEOUS* SOLUTION 95000 UNIT/3.8ML, 7500 UNIT/0.3ML, 25000 UNIT/ML ........................................................................................................... 471FREESTYLE INSULINX TEST ......................................... 472FREESTYLE LITE ............................................................................... 473FREESTYLE LITE TEST ............................................................ 474FREESTYLE TEST .............................................................................. 475frovatriptan succinate ......................................................................... 476gabapentin oral capsule .................................................................. 478gabapentin oral tablet ........................................................................ 477GAMMAGARD ........................................................................................ 479
Index
GAMMAGARD S/D LESS IGA ......................................... 480GAMMAKED .............................................................................................. 481GAMMAPLEX INTRAVENOUS* SOLUTION 5 GM/100ML, 10 GM/200ML, 2.5 GM/50ML ...... 482GAMUNEX-C ............................................................................................. 483ganirelix acetate ........................................................................................ 484gatifloxacin ophthalmic .................................................................... 485GATTEX ............................................................................................................ 486GAVILYTE-C ............................................................................................. 487GAVILYTE-G ............................................................................................. 488ge100 blood glucose test ................................................................. 489GELNIQUE TRANSDERMAL GEL 10 % ........... 490GELNIQUE TRANSDERMAL GEL 3 (28) % (MG/ACT) ........................................................................................................ 491GENERESS FE .......................................................................................... 492GIANVI ................................................................................................................ 493GIAZO ................................................................................................................... 494GILDAGIA ...................................................................................................... 495GILDESS 1.5/30 ....................................................................................... 496GILDESS 1/20 ............................................................................................. 497GILDESS FE 1.5/30 ............................................................................. 498GILDESS FE 1/20 .................................................................................. 499GILENYA ......................................................................................................... 500GILOTRIF ........................................................................................................ 501GLATOPA ....................................................................................................... 502GLUCAGEN DIAGNOSTIC ................................................... 503GLUCAGEN HYPOKIT ............................................................... 504GLUCOCARD 01 BLOOD GLUCOSE DEVICE........................................................................................................................................... 505GLUCOCARD 01 SENSOR PLUS ................................. 506GLUCOCARD EXPRESSION TEST .......................... 507GLUCOCARD VITAL TEST ................................................. 508GLUCOCARD X-SENSOR ...................................................... 509GLUCOCOM BLOOD GLUCOSE MONITOR........................................................................................................................................... 510GLUCOCOM TEST ............................................................................ 511GONAL-F ......................................................................................................... 512GONAL-F RFF ........................................................................................... 513GONAL-F RFF PEN ........................................................................... 514GONAL-F RFF REDIJECT ....................................................... 515GRALISE ORAL TABLET 300 MG ............................ 516GRALISE ORAL TABLET 600 MG ............................ 517GRALISE STARTER ........................................................................ 518granisetron hcl oral ............................................................................... 519guanfacine hcl er ...................................................................................... 520GUARDIAN REAL-TIME SYSTEM PED ........... 521HALAVEN ...................................................................................................... 522HARVONI ........................................................................................................ 523HELIXATE FS ........................................................................................... 524
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,278
![Page 1279: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1279.jpg)
Index
HEMOFIL M INTRAVENOUS* SOLUTION RECONSTITUTED 220-400 UNIT, 250 UNIT, 1000 UNIT, 1700 UNIT, 500 UNIT, 1501-2000 UNIT, 801-1500 UNIT, 401-800 UNIT ...................... 525HEPSERA ......................................................................................................... 526HIZENTRA SUBCUTANEOUS* SOLUTION 10 GM/50ML, 1 GM/5ML, 4 GM/20ML, 2 GM/10ML ......................................................................................................... 527hm nicotine transdermal patch 24 hr 7 mg/24hr........................................................................................................................................... 528HORIZANT ORAL TABLET EXTENDEDRELEASE* 300 MG .................................... 530HORIZANT ORAL TABLET EXTENDEDRELEASE* 600 MG .................................... 529HUMATE-P INTRAVENOUS* SOLUTION RECONSTITUTED 500-1200 UNIT, 1000-2400 UNIT, 250-600 UNIT ......................................................................... 531HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML .............................. 535HUMIRA PEN SUBCUTANEOUS* ............................ 536HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* ........................................................................... 537HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* ........................................................................... 538HUMIRA SUBCUTANEOUS* 10 MG/0.2ML........................................................................................................................................... 532HUMIRA SUBCUTANEOUS* 20 MG/0.4ML........................................................................................................................................... 533HUMIRA SUBCUTANEOUS* 40 MG/0.8ML........................................................................................................................................... 534HYCAMTIN ORAL ............................................................................ 539hydrocod polst-cpm polst er oral liquid extendedrelease* ....................................................................................... 540hydromorphone hcl er ........................................................................ 541ibandronate sodium oral ................................................................. 542ICLUSIG ORAL TABLET 15 MG .................................. 544ICLUSIG ORAL TABLET 45 MG .................................. 543ILARIS .................................................................................................................. 545imatinib mesylate oral tablet 100 mg .............................. 546imatinib mesylate oral tablet 400 mg .............................. 547imiquimod external ................................................................................ 548IMPLANON ................................................................................................... 549INCRELEX ..................................................................................................... 550INFINITY BLOOD GLUCOSE TEST ........................ 551INLYTA .............................................................................................................. 552INTELENCE ORAL TABLET 100 MG, 25 MG........................................................................................................................................... 553INTELENCE ORAL TABLET 200 MG ................... 554INTRON A ....................................................................................................... 555INTROVALE ................................................................................................ 556INVOKANA .................................................................................................. 557
Index
ipratropium bromide nasal .......................................................... 558irbesartan ........................................................................................................... 559irbesartan-hydrochlorothiazide ............................................. 560ISENTRESS ORAL TABLET ................................................ 561ISENTRESS ORAL TABLET CHEWABLE ..... 562ISTODAX ......................................................................................................... 563itraconazole oral ....................................................................................... 564JAKAFI ................................................................................................................ 566JANUMET ....................................................................................................... 567JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-500 MG........................................................................................................................................... 569JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 50-1000 MG ......................................... 568JANUVIA .......................................................................................................... 570JENTADUETO .......................................................................................... 571JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG ....................................... 572JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG ............................................ 573jevantique lo .................................................................................................... 574JINTELI ............................................................................................................... 575JOLESSA ........................................................................................................... 576JOLIVETTE ................................................................................................... 577JUNEL 1.5/30 ............................................................................................... 578JUNEL 1/20 .................................................................................................... 579JUNEL FE 1.5/30 ..................................................................................... 580JUNEL FE 1/20 .......................................................................................... 581JUXTAPID ORAL CAPSULE 20 MG ........................ 583JUXTAPID ORAL CAPSULE 5 MG, 10 MG ... 584JUXTAPID ORAL CAPSULE 60 MG, 40 MG, 30 MG .............................................................................................................................. 582KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 40 MG, 130 MG, 70 MG ........................................................................................ 585KALYDECO ORAL TABLET .............................................. 586KARIVA ............................................................................................................. 587KELNOR 1/35 ............................................................................................. 588KEPIVANCE ................................................................................................ 589ketoconazole oral ..................................................................................... 590ketorolac tromethamine ophthalmic ................................. 591ketorolac tromethamine oral ..................................................... 592KINERET SUBCUTANEOUS* .......................................... 593KOATE-DVI ................................................................................................. 594KOGENATE FS ........................................................................................ 595KOGENATE FS BIO-SET .......................................................... 596KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG........................................................................................................................................... 597
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,279
![Page 1280: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1280.jpg)
Index
KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG, 5-500 MG ........................................................................................................... 598KORLYM .......................................................................................................... 599KOVALTRY ................................................................................................. 600kroger blood glucose test ............................................................... 601kroger premium glucose test ...................................................... 602kroger test .......................................................................................................... 603KURVELO ....................................................................................................... 604KUVAN ORAL PACKET 500 MG ................................. 605KUVAN ORAL TABLET SOLUBLE ......................... 605LAMISIL ORAL PACKET 125 MG ............................. 606LAMISIL ORAL PACKET 187.5 MG ........................ 607lamotrigine er oral tablet extended release 24 hr*100 mg, 25 mg .............................................................................................. 614lamotrigine er oral tablet extended release 24 hr*200 mg .................................................................................................................... 611lamotrigine er oral tablet extended release 24 hr*250 mg, 300 mg .......................................................................................... 612lamotrigine er oral tablet extended release 24 hr*50 mg ........................................................................................................................ 613lamotrigine oral tablet dispersible 100 mg, 200 mg........................................................................................................................................... 608lamotrigine oral tablet dispersible 25 mg ................. 610lamotrigine oral tablet dispersible 50 mg ................. 609lansoprazole oral capsule delayed release .............. 615LANTUS ............................................................................................................. 616LANTUS SOLOSTAR SUBCUTANEOUS* ..... 617LARIN FE 1.5/30 ..................................................................................... 618LASTACAFT ............................................................................................... 619latanoprost ophthalmic ..................................................................... 620LATUDA ORAL TABLET 20 MG, 120 MG, 60 MG, 40 MG ..................................................................................................... 621LATUDA ORAL TABLET 80 MG ................................. 622LEENA .................................................................................................................. 623leflunomide oral ......................................................................................... 624LEMTRADA ................................................................................................. 625LESSINA ............................................................................................................ 626LETAIRIS ......................................................................................................... 627LEUKINE INTRAVENOUS* ................................................ 628leuprolide acetate injection ......................................................... 629levalbuterol tartrate hfa ................................................................... 630levetiracetam er oral tablet extended release 24 hr* 500 mg ........................................................................................................ 631levetiracetam er oral tablet extended release 24 hr* 750 mg ........................................................................................................ 632levocetirizine dihydrochloride oral solution .......... 634levocetirizine dihydrochloride oral tablet ................ 633LEVONEST .................................................................................................... 635levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg, 0.1-0.02 & 0.01 mg .................................................................... 636
Index
levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg .................................................................................................................. 637LEVORA 0.15/30 (28) ...................................................................... 638LIALDA .............................................................................................................. 639liberty blood glucose meter ......................................................... 640liberty blood glucose monitor ................................................... 641LIBERTY NEXT GENERATION TEST ................. 642LIBERTY NXT GENERATION MONITOR ..... 643liberty test ........................................................................................................... 644lidocaine external ointment ......................................................... 645lidocaine external patch 5 % ..................................................... 647lidocaine-prilocaine external cream ................................ 648lindane external lotion ....................................................................... 650linezolid oral suspension reconstituted ........................ 651linezolid oral tablet ................................................................................ 652LINZESS ............................................................................................................ 653LIVALO .............................................................................................................. 654LO LOESTRIN FE ................................................................................ 655LOESTRIN FE 1.5/30 ....................................................................... 656LOESTRIN FE 1/20 ............................................................................. 657LOMEDIA 24 FE .................................................................................... 658LORYNA ........................................................................................................... 659LOSEASONIQUE .................................................................................. 660lovastatin ............................................................................................................. 661LOW-OGESTREL ................................................................................. 662LUMIGAN OPHTHALMIC SOLUTION 0.01 %........................................................................................................................................... 663LUMIZYME .................................................................................................. 664LUPANETA PACK .............................................................................. 665LUPRON DEPOT ................................................................................... 666LUPRON DEPOT-PED ................................................................... 667LUTERA ............................................................................................................. 668LYRICA .............................................................................................................. 669LYZA ...................................................................................................................... 670malathion external .................................................................................. 671marlissa ................................................................................................................ 672MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 300 MG, 420 MG, 360 MG ................................................................................................................. 673MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 240 MG ...................................................... 674MAXIMA BLOOD GLUCOSE TEST ........................ 675medroxyprogesterone acetate intramuscular* suspension ......................................................................................................... 676meijer blood glucose test ................................................................ 677meijer premium glucose test ....................................................... 678memantine hcl oral tablet 10 mg, 5 mg ........................ 679memantine hcl oral tablet 5 (28)-10 (21) mg ........ 680MENOPUR ...................................................................................................... 681MENOSTAR ................................................................................................. 682mesalamine oral ......................................................................................... 683
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,280
![Page 1281: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1281.jpg)
Index
METADATE ER ORAL TABLET EXTENDEDRELEASE* 20 MG ........................................ 684metaxalone oral tablet 400 mg ................................................ 686metformin hcl er (mod) ..................................................................... 687methamphetamine hcl ......................................................................... 688METHYLIN ORAL TABLET CHEWABLE ..... 689methylphenidate hcl er (cd) ......................................................... 701methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg .................................................. 703methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg ........................................................................ 705methylphenidate hcl er oral tablet extended release 24 hr* 27 mg, 18 mg, 54 mg ....................................................... 693methylphenidate hcl er oral tablet extended release 24 hr* 36 mg .................................................................................................. 700methylphenidate hcl er oral tablet extendedrelease* 10 mg, 20 mg ............................................. 696methylphenidate hcl er oral tablet extendedrelease* 27 mg, 18 mg, 54 mg ....................... 694methylphenidate hcl er oral tablet extendedrelease* 36 mg ................................................................... 698methylphenidate hcl oral solution 10 mg/5ml ...... 690methylphenidate hcl oral solution 5 mg/5ml .......... 691methylphenidate hcl oral tablet .............................................. 692metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 50 mg .................................................. 709metoprolol succinate er oral tablet extended release 24 hr* 200 mg ........................................................................ 707metoprolol succinate er oral tablet extended release 24 hr* 25 mg ........................................................................... 708MIACALCIN INJECTION ......................................................... 710MICRODOT TEST ............................................................................... 711MICROGESTIN 1.5/30 ................................................................... 712MICROGESTIN 1/20 ......................................................................... 713MICROGESTIN FE 1.5/30 ......................................................... 714MICROGESTIN FE 1/20 .............................................................. 715MIMVEY ........................................................................................................... 716MIRCETTE ..................................................................................................... 717MIRENA (52 MG) ................................................................................. 718mirtazapine oral ......................................................................................... 719modafinil .............................................................................................................. 720MODICON (28) ......................................................................................... 722MONOCLATE-P ..................................................................................... 723MONO-LINYAH ..................................................................................... 724montelukast sodium oral ................................................................. 725montelukast sodium oral ................................................................. 726morphine sulfate er beads oral capsule extended release 24 hour 90 mg, 120 mg, 75 mg, 45 mg ... 728morphine sulfate er oral capsule extended release 24 hour ................................................................................................................... 727MOZOBIL ........................................................................................................ 729
Index
MULTAQ .......................................................................................................... 730MYGLUCOHEALTH TEST .................................................... 731MYOBLOC ..................................................................................................... 732MYORISAN ORAL CAPSULE 20 MG, 40 MG, 10 MG ..................................................................................................................... 733MYRBETRIQ .............................................................................................. 734MYTESI .............................................................................................................. 735MYZILRA ........................................................................................................ 736naftifine hcl ...................................................................................................... 737NAFTIN EXTERNAL GEL 1 % ......................................... 738NAGLAZYME ........................................................................................... 739naratriptan hcl ............................................................................................. 740NATAZIA ......................................................................................................... 741NECON 0.5/35 (28) .............................................................................. 742NECON 1/35 (28) ................................................................................... 743NECON 1/50 (28) ................................................................................... 744NECON 10/11 (28) ................................................................................ 745NEULASTA DELIVERY KIT SUBCUTANEOUS* ........................................................................... 747NEULASTA SUBCUTANEOUS* ................................... 746NEUPOGEN INJECTION ........................................................... 748NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML, 300 MCG/ML ..................................................... 748NEUPRO ............................................................................................................ 749NEUTEK 2TEK GLUCOSE/PRESSURE ............... 750NEUTEK 2TEK TEST ..................................................................... 751nevirapine er oral tablet extended release 24 hr*100 mg .................................................................................................................... 752nevirapine er oral tablet extended release 24 hr*400 mg .................................................................................................................... 753NEXAVAR ...................................................................................................... 754NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE ......................................................................................................... 757NEXIUM ORAL PACKET ........................................................ 755NEXPLANON ............................................................................................. 758NEXT CHOICE ONE DOSE ................................................... 759NICODERM CQ ....................................................................................... 760nicotine step 1 ............................................................................................... 762nicotine step 2 ............................................................................................... 763nicotine step 3 ............................................................................................... 764nicotine transdermal patch 24 hr ......................................... 761NICOTROL ..................................................................................................... 765NICOTROL NS ......................................................................................... 766NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG .......................................................... 767NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG .......................................................... 768NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG .......................................................... 769NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG .......................................................... 770
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,281
![Page 1282: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1282.jpg)
Index
nifedipine er oral tablet extended release 24 hr* 30 mg, 90 mg ........................................................................................................... 771nifedipine er oral tablet extended release 24 hr* 60 mg ................................................................................................................................. 772nifedipine er osmotic release oral tablet extended release 24 hr* 60 mg ........................................................................... 774nifedipine er osmotic release oral tablet extended release 24 hr* 90 mg, 30 mg ...................................................... 773NIKKI ..................................................................................................................... 775nisoldipine er oral tablet extended release 24 hr*20 mg, 25.5 mg, 40 mg, 8.5 mg, 17 mg, 34 mg ... 776nisoldipine er oral tablet extended release 24 hr*30 mg ........................................................................................................................ 777nitroglycerin translingual solution .................................... 778NORA-BE ......................................................................................................... 779norethindrone oral .................................................................................. 780NORINYL 1+35 (28) .......................................................................... 781NORINYL 1+50 (28) .......................................................................... 782NORLYROC ................................................................................................. 783NORTREL 0.5/35 (28) ..................................................................... 784NORTREL 1/35 (21) ........................................................................... 785NORTREL 1/35 (28) ........................................................................... 786NOVA MAX BLOOD GLUCOSE SYSTEM DEVICE ............................................................................................................... 787NOVA MAX GLUCOSE TEST ........................................... 788NOVAREL ....................................................................................................... 789NOVOEIGHT .............................................................................................. 790NOVOLIN 70/30 ...................................................................................... 791NOVOLIN 70/30 RELION ......................................................... 792NOVOLIN N ................................................................................................. 793NOVOLIN N RELION .................................................................... 794NOVOLIN R .................................................................................................. 795NOVOLIN R RELION ..................................................................... 796NOVOLOG ..................................................................................................... 797NOVOLOG FLEXPEN SUBCUTANEOUS* ... 798NOVOLOG MIX 70/30 ................................................................... 799NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* ........................................................................... 800NOVOLOG PENFILL SUBCUTANEOUS* ...... 801NOVOSEVEN ............................................................................................. 802NOVOSEVEN RT .................................................................................. 803NOXAFIL ORAL SUSPENSION ..................................... 804NUCYNTA ...................................................................................................... 805NUCYNTA ER ........................................................................................... 806NUEDEXTA .................................................................................................. 807NULOJIX ........................................................................................................... 808NUVARING ................................................................................................... 809NUWIQ ................................................................................................................ 810OCELLA ............................................................................................................. 811
Index
OCTAGAM INTRAVENOUS* SOLUTION 1 GM/20ML, 10 GM/200ML, 2 GM/20ML, 20 GM/200ML, 2.5 GM/50ML, 25 GM/500ML, 5 GM/100ML ...................................................................................................... 812octreotide acetate injection solution 500 mcg/ml, 100 mcg/ml, 1000 mcg/ml, 50 mcg/ml, 200 mcg/ml........................................................................................................................................... 813ODEFSEY ......................................................................................................... 814OGESTREL .................................................................................................... 815olanzapine oral tablet 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg ...................................................................................................................... 816olanzapine oral tablet 2.5 mg ................................................... 817olanzapine oral tablet dispersible ....................................... 816olanzapine-fluoxetine hcl ............................................................... 818OLEPTRO ......................................................................................................... 819omega-3-acid ethyl esters .............................................................. 820omeprazole-sodium bicarbonate oral capsule20-1100 mg ...................................................................................................... 821OMNARIS ........................................................................................................ 822OMNITROPE ............................................................................................... 823ON CALL PLUS BLOOD GLUCOSE ........................ 824ON CALL VIVID BLOOD GLUCOSE ..................... 825ondansetron ..................................................................................................... 826ondansetron hcl oral solution ................................................... 828ondansetron hcl oral tablet 24 mg, 4 mg .................... 829ondansetron hcl oral tablet 8 mg ......................................... 827ONETOUCH TEST .............................................................................. 830ONETOUCH ULTRA BLUE .................................................. 831ONETOUCH VERIO IN VITRO STRIP ................. 832ONFI ORAL SUSPENSION ..................................................... 833ONFI ORAL TABLET 10 MG, 20 MG ..................... 834ONGLYZA ...................................................................................................... 835OPANA ER ORAL ............................................................................... 836OPSUMIT ......................................................................................................... 837OPTIUM TEST .......................................................................................... 838OPTIUMEZ TEST ................................................................................. 839ORAVIG ............................................................................................................. 840ORENCIA CLICKJECT ................................................................. 843ORENCIA INTRAVENOUS* ............................................... 842ORENCIA SUBCUTANEOUS* ......................................... 841ORKAMBI ....................................................................................................... 844ORKAMBI ....................................................................................................... 845ORSYTHIA ..................................................................................................... 846ORTHO MICRONOR ....................................................................... 847ORTHO TRI-CYCLEN (28) ..................................................... 848ORTHO TRI-CYCLEN LO ....................................................... 849ORTHO-CEPT (28) .............................................................................. 850ORTHO-CYCLEN (28) ................................................................... 851ORTHO-NOVUM 1/35 (28) ..................................................... 852ORTHO-NOVUM 7/7/7 (28) ................................................... 853OVCON-35 (28) ........................................................................................ 854
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,282
![Page 1283: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1283.jpg)
Index
OVIDREL ......................................................................................................... 855OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG .......................... 857OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 600 MG ...................................................... 856oxybutynin chloride er ....................................................................... 859oxybutynin chloride oral tablet ............................................... 858oxycodone-ibuprofen ........................................................................... 860OXYCONTIN ORAL ........................................................................ 861oxymorphone hcl ....................................................................................... 862oxymorphone hcl er oral tablet extended release 12 hr* 10 mg ............................................................................................................ 863oxymorphone hcl er oral tablet extended release 12 hr* 30 mg ............................................................................................................ 865oxymorphone hcl er oral tablet extended release 12 hr* 40 mg, 5 mg, 7.5 mg, 15 mg, 20 mg ...................... 864paliperidone er oral tablet extended release 24 hr*1.5 mg, 9 mg, 3 mg ................................................................................. 866paliperidone er oral tablet extended release 24 hr*6 mg ........................................................................................................................... 867PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 4200-10000 UNIT, 10500-25000 UNIT, 16800-40000 UNIT, 21000-37000 UNIT ............................................................................... 868pancrelipase (lip-prot-amyl) ...................................................... 869PARAGARD INTRAUTERINE COPPER ............ 870paricalcitol oral ......................................................................................... 871paroxetine hcl er oral tablet extended release 24 hr* 25 mg ............................................................................................................ 874paroxetine hcl er oral tablet extended release 24 hr* 37.5 mg, 12.5 mg ........................................................................... 875paroxetine hcl oral tablet 10 mg, 20 mg ..................... 872paroxetine hcl oral tablet 30 mg, 40 mg ..................... 873peg 3350/electrolytes ........................................................................... 876peg-3350/electrolytes .......................................................................... 877PEGASYS PROCLICK ................................................................... 879PEGASYS SUBCUTANEOUS* SOLUTION........................................................................................................................................... 878PEG-INTRON .............................................................................................. 880PEG-INTRON REDIPEN ............................................................. 881PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS* KIT 50 MCG/0.5ML, 150 MCG/0.5ML, 120 MCG/0.5ML ........................................... 882PENTASA ORAL CAPSULE EXTENDED RELEASE* 250 MG ........................................................................... 883PENTASA ORAL CAPSULE EXTENDED RELEASE* 500 MG ........................................................................... 884PERFOROMIST ....................................................................................... 885PERTZYE ......................................................................................................... 886PHARMACIST CHOICE AUTOCODE ................... 887PHILITH ............................................................................................................. 888
Index
PICATO EXTERNAL GEL 0.015 % ............................ 890PICATO EXTERNAL GEL 0.05 % ................................ 889pioglitazone hcl ........................................................................................... 891pioglitazone hcl-glimepiride ...................................................... 892pioglitazone hcl-metformin hcl ............................................... 893PLAN B ONE-STEP ........................................................................... 894PLEGRIDY ..................................................................................................... 895PLEGRIDY STARTER PACK .............................................. 896POCKETCHEM EZ TEST .......................................................... 897POMALYST .................................................................................................. 898PORTIA-28 ..................................................................................................... 899POTIGA ORAL TABLET 200 MG, 400 MG, 300 MG .............................................................................................................................. 900POTIGA ORAL TABLET 50 MG .................................... 901PRALUENT ................................................................................................... 902pramipexole dihydrochloride er ............................................ 903pravastatin sodium ................................................................................. 904PRECISION PCX .................................................................................... 905PRECISION PCX PLUS TEST ............................................. 906PRECISION POINT OF CARE TEST ........................ 907PRECISION QID TEST .................................................................. 908PRECISION SOF-TACT TEST ............................................ 909PRECISION XTRA BLOOD GLUCOSE ............... 911PRECISION XTRA DEVICE ................................................. 910PRECISION XTRA MONITOR .......................................... 912PREFEST ........................................................................................................... 913PREGNYL ........................................................................................................ 914PREMARIN ORAL .............................................................................. 915PREMPHASE .............................................................................................. 916PREMPRO ....................................................................................................... 917PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG ................................................................................... 918PREVIFEM ..................................................................................................... 919PREZISTA ORAL SUSPENSION ................................... 922PREZISTA ORAL TABLET 600 MG, 75 MG, 150 MG .............................................................................................................................. 920PREZISTA ORAL TABLET 800 MG ......................... 921PRISTIQ .............................................................................................................. 923PRIVIGEN ....................................................................................................... 924PROAIR HFA .............................................................................................. 925PROCRIT ........................................................................................................... 926PRODIGY AUTOCODE BLOOD GLUCOSE DEVICE ............................................................................................................... 927PRODIGY NO CODING BLOOD GLUC ............. 928PROFILNINE INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT .......................................... 929PROFILNINE SD .................................................................................... 930progesterone micronized oral .................................................. 931PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG ................................................ 932PROLEUKIN ................................................................................................ 933
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,283
![Page 1284: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1284.jpg)
Index
PROLIA ............................................................................................................... 934PROMACTA ORAL TABLET 25 MG, 12.5 MG, 50 MG ..................................................................................................................... 935propafenone hcl er .................................................................................. 936PROVENTIL HFA ................................................................................ 937PULMICORT FLEXHALER ................................................... 938PULMOZYME ........................................................................................... 939QNASL ................................................................................................................. 940QNASL CHILDRENS ...................................................................... 941QUASENSE ................................................................................................... 942quetiapine fumarate oral tablet 100 mg, 50 mg........................................................................................................................................... 943quetiapine fumarate oral tablet 200 mg ...................... 946quetiapine fumarate oral tablet 25 mg .......................... 944quetiapine fumarate oral tablet 300 mg, 400 mg........................................................................................................................................... 945QUILLIVANT XR ................................................................................. 947quinine sulfate oral ................................................................................ 949ra blood glucose monitor ............................................................... 950RA TRUETEST TEST ...................................................................... 951rabeprazole sodium ............................................................................... 952RAJANI ................................................................................................................ 954RANEXA ........................................................................................................... 955RAVICTI ............................................................................................................ 956REBETOL ORAL SOLUTION ............................................ 957REBIF REBIDOSE SUBCUTANEOUS* ............... 959REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* ........................................................................... 960REBIF SUBCUTANEOUS* ..................................................... 958REBIF TITRATION PACK SUBCUTANEOUS*........................................................................................................................................... 961RECLAST ......................................................................................................... 962RECLIPSEN ................................................................................................... 963RECOMBINATE ..................................................................................... 964RECTIV ............................................................................................................... 965REFUAH PLUS BLOOD GLUCOSE TEST ...... 966RELENZA DISKHALER ............................................................. 967RELION CONFIRM/MICRO TEST .............................. 968RELION PRIME MONITOR .................................................. 969RELION PRIME TEST ................................................................... 970RELION ULTIMA TEST ............................................................. 971RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML ........................................................................................................ 972RELISTOR SUBCUTANEOUS* SOLUTION 8 MG/0.4ML ........................................................................................................ 973RELPAX ............................................................................................................. 974REMICADE ................................................................................................... 975REMODULIN .............................................................................................. 976repaglinide-metformin hcl ............................................................ 977REPATHA ........................................................................................................ 978REPATHA PUSHTRONEX SYSTEM ....................... 979
Index
REPATHA SURECLICK ............................................................. 980REPRONEX ................................................................................................... 981RESCULA ........................................................................................................ 982REVEAL BLOOD GLUCOSE TEST ........................... 983REVLIMID ...................................................................................................... 984REXALL BLOOD GLUCOSE TEST ........................... 985REXULTI .......................................................................................................... 986REYATAZ ORAL CAPSULE 200 MG ..................... 987REYATAZ ORAL CAPSULE 300 MG, 150 MG........................................................................................................................................... 988RIASTAP ........................................................................................................... 989RIGHTEST GS100 BLOOD GLUCOSE ................. 990RIGHTEST GS300 BLOOD GLUCOSE ................. 991RIGHTEST GS550 BLOOD GLUCOSE ................. 992risedronate sodium oral tablet 150 mg ......................... 995risedronate sodium oral tablet 5 mg, 30 mg, 35 mg........................................................................................................................................... 993risedronate sodium oral tablet delayed release........................................................................................................................................... 994RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 2 MG, 1 MG ......................... 999RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 3 MG ..................................................................... 1000RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 4 MG ..................................................................... 1001risperidone oral tablet 1 mg, 0.25 mg, 0.5 mg, 2 mg........................................................................................................................................... 997risperidone oral tablet 3 mg ....................................................... 998risperidone oral tablet 4 mg ....................................................... 996risperidone oral tablet dispersible 0.25 mg, 1 mg, 2 mg, 0.5 mg ......................................................................................................... 997risperidone oral tablet dispersible 3 mg ..................... 998risperidone oral tablet dispersible 4 mg ..................... 996RITUXAN INTRAVENOUS* SOLUTION ..... 1002rivastigmine ................................................................................................. 1003rizatriptan benzoate ........................................................................... 1004ropinirole hcl er oral tablet extended release 24 hr* 12 mg ........................................................................................................ 1006ropinirole hcl er oral tablet extended release 24 hr* 6 mg, 8 mg, 4 mg, 2 mg ..................................................... 1005rosuvastatin calcium ......................................................................... 1007ROZEREM ................................................................................................... 1008SABRIL ............................................................................................................ 1009SABRIL ............................................................................................................ 1010SAFYRAL ..................................................................................................... 1011SAMSCA ORAL TABLET 15 MG ............................. 1013SAMSCA ORAL TABLET 30 MG ............................. 1012SANCUSO .................................................................................................... 1014SAPHRIS ........................................................................................................ 1015SAPHRIS ........................................................................................................ 1016SAVELLA ..................................................................................................... 1017
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,284
![Page 1285: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1285.jpg)
Index
SAVELLA TITRATION PACK ...................................... 1018SEASONIQUE ........................................................................................ 1019SELZENTRY ............................................................................................ 1020SENSIPAR ................................................................................................... 1021SEREVENT DISKUS .................................................................... 1022SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG ...................... 1023SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 300 MG, 400 MG, 50 MG....................................................................................................................................... 1024sertraline hcl oral concentrate ............................................ 1026sertraline hcl oral tablet 100 mg ...................................... 1028sertraline hcl oral tablet 25 mg .......................................... 1025sertraline hcl oral tablet 50 mg .......................................... 1027SHAROBEL ............................................................................................... 1029sildenafil citrate oral ........................................................................ 1030SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR* 500-40 MG, 1000-40 MG....................................................................................................................................... 1031SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR* 750-20 MG, 500-20 MG, 1000-20 MG ................................................................................................ 1032SIMPONI ARIA .................................................................................... 1034SIMPONI SUBCUTANEOUS* ........................................ 1033SIMULECT ................................................................................................. 1035simvastatin oral ....................................................................................... 1036SMARTEST BLOOD GLUCOSE TEST .............. 1037SMARTEST EJECT ......................................................................... 1038SMARTEST PROTEGE ............................................................. 1039sodium phenylbutyrate ................................................................. 1040sodium phenylbutyrate oral powder 3 gm/tsp....................................................................................................................................... 1040SOLIA ................................................................................................................ 1041SOLUS V2 TEST ................................................................................. 1042SOMATULINE DEPOT ............................................................. 1043SOMAVERT .............................................................................................. 1044SOVALDI ...................................................................................................... 1045SPIRIVA HANDIHALER ........................................................ 1046SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 1.25 MCG/ACT ............................................... 1047SPORANOX ORAL SOLUTION .................................. 1048SPRINTEC 28 .......................................................................................... 1050SPRYCEL ORAL TABLET 140 MG, 100 MG....................................................................................................................................... 1052SPRYCEL ORAL TABLET 50 MG, 20 MG, 80 MG, 70 MG .................................................................................................. 1051SRONYX ........................................................................................................ 1053STAVZOR .................................................................................................... 1054STELARA INTRAVENOUS* ........................................... 1055STELARA SUBCUTANEOUS* ..................................... 1056STIMATE ...................................................................................................... 1057
Index
STIOLTO RESPIMAT ................................................................. 1058STIVARGA ................................................................................................. 1059STRATTERA ............................................................................................ 1060STRIANT ....................................................................................................... 1061STRIBILD ..................................................................................................... 1062SUBOXONE SUBLINGUAL FILM 12-3 MG....................................................................................................................................... 1065SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG, 2-0.5 MG .......................................................................................... 1063sulfasalazine oral .................................................................................. 1067SULFAZINE .............................................................................................. 1068SULFAZINE EC ................................................................................... 1069sumatriptan nasal ................................................................................. 1070sumatriptan succinate oral ....................................................... 1073sumatriptan succinate refill subcutaneous* ........ 1074sumatriptan succinate subcutaneous* 6 mg/0.5ml, 4 mg/0.5ml ..................................................................................................... 1072sumatriptan succinate subcutaneous* solution 4 mg/0.5ml ........................................................................................................... 1072sumatriptan succinate subcutaneous* solution 6 mg/0.5ml ........................................................................................................... 1071SUPPRELIN LA ................................................................................... 1075SURE EDGE GLUCOSE MONITOR ...................... 1076SURE EDGE TEST ........................................................................... 1077SURECHEK BLOOD GLUCOSE MONITOR DEVICE ........................................................................................................... 1078SURECHEK BLOOD GLUCOSE TEST ............. 1079SURESTEP PRO LINEARITY ......................................... 1080SURESTEP PRO TEST ............................................................... 1081SURE-TEST EASYPLUS MINI METER ........... 1082SURE-TEST EASYPLUS MINI TEST .................. 1083SUTENT .......................................................................................................... 1084SYEDA .............................................................................................................. 1085SYLATRON SUBCUTANEOUS* KIT 300 MCG, 600 MCG, 4 X 300 MCG, 200 MCG, 4 X 200 MCG ..................................................................................................................... 1086SYMBICORT ........................................................................................... 1087SYMLINPEN 120 SUBCUTANEOUS* ............... 1088SYMLINPEN 60 SUBCUTANEOUS* ................... 1090SYNAGIS ...................................................................................................... 1092SYNRIBO ...................................................................................................... 1093TACLONEX EXTERNAL SUSPENSION ........ 1094TAKE ACTION ..................................................................................... 1095TAMIFLU ORAL CAPSULE ............................................. 1096TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML .......................................... 1097TARCEVA ................................................................................................... 1098TARGRETIN ............................................................................................ 1099TASIGNA ...................................................................................................... 1100TAYTULLA ............................................................................................... 1101TAZORAC ................................................................................................... 1102
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,285
![Page 1286: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1286.jpg)
Index
TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG ............................................ 1103TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 360 MG, 180 MG, 120 MG ............................................................................................................. 1104TECHNIVIE ............................................................................................... 1105TEKTURNA .............................................................................................. 1106TEKTURNA HCT .............................................................................. 1107TELCARE BLOOD GLUCOSE TEST ................... 1108telmisartan ..................................................................................................... 1109telmisartan-amlodipine ................................................................. 1110telmisartan-hctz ...................................................................................... 1111temazepam oral capsule 7.5 mg, 22.5 mg .............. 1112temozolomide ............................................................................................. 1113TESTIM ............................................................................................................ 1114TESTOPEL .................................................................................................. 1115testosterone cypionate intramuscular* solution 100 mg/ml .................................................................................................................... 1119testosterone cypionate intramuscular* solution 200 mg/ml .................................................................................................................... 1118testosterone transdermal gel 10 mg/act (2%) ... 1117testosterone transdermal gel 50 mg/5gm (1%), 12.5 mg/act (1%) .................................................................................................. 1116tetrabenazine oral tablet 12.5 mg .................................... 1120tetrabenazine oral tablet 25 mg .......................................... 1121TEVETEN HCT ORAL TABLET 600-25 MG....................................................................................................................................... 1122tgt blood glucose test ....................................................................... 1123THALOMID ............................................................................................... 1124tiagabine hcl oral tablet 2 mg ............................................... 1126tiagabine hcl oral tablet 4 mg ............................................... 1125TILIA FE ........................................................................................................ 1127TIROSINT ..................................................................................................... 1128tobramycin inhalation ..................................................................... 1129tolterodine tartrate .............................................................................. 1130tolterodine tartrate er ...................................................................... 1131topiramate oral capsule sprinkle ...................................... 1132TOVIAZ ........................................................................................................... 1133TRACLEER ................................................................................................ 1134TRADJENTA ............................................................................................ 1135tramadol hcl er (biphasic) ......................................................... 1137tramadol hcl er oral tablet extended release 24 hr*....................................................................................................................................... 1136tramadol-acetaminophen ............................................................ 1138tranexamic acid oral ........................................................................ 1139TRAVATAN Z ....................................................................................... 1140tretinoin external ................................................................................... 1141TRETIN-X EXTERNAL CREAM 0.0375 %....................................................................................................................................... 1142TRETTEN ..................................................................................................... 1143triamcinolone acetonide nasal aerosol† ................. 1144
Index
TRIBENZOR ............................................................................................. 1145TRI-LEGEST FE .................................................................................. 1146TRI-LINYAH ............................................................................................ 1147TRINESSA (28) ..................................................................................... 1148TRI-NORINYL (28) ......................................................................... 1149TRI-PREVIFEM ................................................................................... 1150TRI-SPRINTEC ..................................................................................... 1151TRIVORA (28) ....................................................................................... 1152trospium chloride .................................................................................. 1153trospium chloride er .......................................................................... 1154TRUETEST TEST .............................................................................. 1155TRUETRACK TEST ....................................................................... 1156TRUVADA .................................................................................................. 1157TRUVADA .................................................................................................. 1158TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT ........................................................................................ 1159TUSSICAPS ............................................................................................... 1160TYKERB ......................................................................................................... 1161TYZEKA ......................................................................................................... 1162UCERIS ORAL ...................................................................................... 1163ULESFIA ........................................................................................................ 1164ULORIC ........................................................................................................... 1165ULTIMA TEST ...................................................................................... 1166ULTRATRAK ACTIVE ............................................................. 1167ULTRATRAK PRO .......................................................................... 1168ULTRATRAK PRO TEST ...................................................... 1169ULTRATRAK ULTIMATE MONITOR .............. 1170ULTRATRAK ULTIMATE TEST ............................... 1171ULTRESA ..................................................................................................... 1172VALCYTE .................................................................................................... 1173valganciclovir hcl ................................................................................. 1174valsartan .......................................................................................................... 1175valsartan-hydrochlorothiazide ............................................ 1176VECTIBIX INTRAVENOUS* SOLUTION 400 MG/20ML, 100 MG/5ML ......................................................... 1177VELCADE INJECTION ............................................................ 1178VELIVET ....................................................................................................... 1179venlafaxine hcl er oral capsule extended release 24 hour 150 mg ................................................................................................. 1185venlafaxine hcl er oral capsule extended release 24 hour 75 mg, 37.5 mg ......................................................................... 1184venlafaxine hcl oral tablet 100 mg, 25 mg ........... 1181venlafaxine hcl oral tablet 37.5 mg ............................... 1182venlafaxine hcl oral tablet 50 mg ..................................... 1180venlafaxine hcl oral tablet 75 mg ..................................... 1183VERAMYST .............................................................................................. 1186verapamil hcl er oral capsule extended release 24 hour 200 mg ................................................................................................. 1188verapamil hcl er oral capsule extended release 24 hour 300 mg, 100 mg ....................................................................... 1187
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,286
![Page 1287: 2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1](https://reader033.vdocument.in/reader033/viewer/2022060504/5f1e03308b14e30aeb330f48/html5/thumbnails/1287.jpg)
Index
VESICARE .................................................................................................. 1189VICTORY AGM-4000 TEST .............................................. 1190VICTORY BLOOD GLUCOSE SYSTEM ........ 1191VICTOZA SUBCUTANEOUS* ...................................... 1192VICTRELIS ................................................................................................. 1193VIEKIRA PAK ....................................................................................... 1194VIEKIRA XR ............................................................................................ 1195VIIBRYD ORAL KIT .................................................................... 1197VIIBRYD ORAL TABLET .................................................... 1196VIIBRYD ORAL TABLET .................................................... 1198VIIBRYD STARTER PACK ................................................ 1199VIMPAT ORAL TABLET ...................................................... 1200VIOKACE ..................................................................................................... 1201viorele .................................................................................................................. 1202VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG .................................................. 1203VIREAD ORAL TABLET ....................................................... 1204VISTOGARD ............................................................................................ 1205VOCAL POINT BLOOD GLUCOSE TEST ... 1206voriconazole oral tablet ................................................................ 1207VOTRIENT ................................................................................................. 1208VPRIV ................................................................................................................ 1209VYTORIN ..................................................................................................... 1210VYVANSE ................................................................................................... 1211WAVESENSE KEYNOTE PRO METER .......... 1213WAVESENSE PRESTO ............................................................ 1214WELCHOL ORAL PACKET .............................................. 1215WERA ................................................................................................................ 1216WIDE-SEAL DIAPHRAGM 60 ....................................... 1217WIDE-SEAL DIAPHRAGM 65 ....................................... 1218WIDE-SEAL DIAPHRAGM 70 ....................................... 1219WIDE-SEAL DIAPHRAGM 75 ....................................... 1220WIDE-SEAL DIAPHRAGM 80 ....................................... 1221WIDE-SEAL DIAPHRAGM 85 ....................................... 1222WIDE-SEAL DIAPHRAGM 90 ....................................... 1223WIDE-SEAL DIAPHRAGM 95 ....................................... 1224WILATE INTRAVENOUS* KIT .................................. 1225WYMZYA FE .......................................................................................... 1226XALKORI ..................................................................................................... 1227XELJANZ ...................................................................................................... 1228XELJANZ XR .......................................................................................... 1229XENAZINE ORAL TABLET 12.5 MG ................. 1231XENAZINE ORAL TABLET 25 MG ...................... 1230XEOMIN ......................................................................................................... 1232XGEVA ............................................................................................................ 1233XIAFLEX ....................................................................................................... 1234XIFAXAN ORAL TABLET 200 MG ....................... 1236XIFAXAN ORAL TABLET 550 MG ....................... 1235XTANDI .......................................................................................................... 1237XULANE ........................................................................................................ 1238XURIDEN ..................................................................................................... 1239
Index
XYNTHA INTRAVENOUS* KIT 2000 UNIT, 1000 UNIT, 250 UNIT, 500 UNIT ................................ 1240XYNTHA SOLOFUSE INTRAVENOUS* KIT 3000 UNIT .................................................................................................... 1241XYREM ............................................................................................................ 1242YASMIN 28 ................................................................................................ 1243YAZ ....................................................................................................................... 1244YERVOY ....................................................................................................... 1245zaleplon ............................................................................................................. 1246ZARAH ............................................................................................................. 1247ZAVESCA .................................................................................................... 1248ZEGERID OTC ...................................................................................... 1249ZELAPAR ..................................................................................................... 1250ZELBORAF ................................................................................................ 1251ZEMAIRA ..................................................................................................... 1252ZENATANE ............................................................................................... 1253ZENCHENT ............................................................................................... 1254ZENCHENT FE ..................................................................................... 1255ZEPATIER ................................................................................................... 1256ZETIA ................................................................................................................. 1257ZETONNA ................................................................................................... 1258ZIOPTAN ....................................................................................................... 1259ziprasidone hcl ......................................................................................... 1260ZIRGAN .......................................................................................................... 1261zoledronic acid intravenous* concentrate ............ 1262zoledronic acid intravenous* solution ....................... 1262ZOLINZA ...................................................................................................... 1263zolmitriptan oral .................................................................................... 1264zolpidem tartrate er ........................................................................... 1266zolpidem tartrate oral ..................................................................... 1265ZOMETA ....................................................................................................... 1267ZOMIG NASAL SOLUTION 5 MG .......................... 1268ZOVIA 1/35E (28) .............................................................................. 1269ZOVIA 1/50E (28) .............................................................................. 1270ZOVIRAX EXTERNAL CREAM ................................. 1271ZYTIGA ........................................................................................................... 1272
2016 Innovation Health Leap Drug GuideLast update 12/2016
1,287